[Off target of distal interlocking screw in short cephalomedullary nail fixation for intertrochanteric femur fractures]

Objective

To analyze the causes and treatment of off target of the distal interlocking screws when short cephalomeduallry nails were installed through jig-guided targeting device, and to put forward the technical points to prevent off target.

Methods

Retrospective analysis of 9 patients with intertrochanteric fractures treated between July 2014 and June 2023 was conducted, in which off target occurred during the insertion of the distal interlocking screw by jig-guided targeting device in short cephalomedullary nailling (<24 cm). There were 1 male and 8 females, with an average age of 82.7 years (range, 73-94 years). There were 3 cases of type A1, 5 cases of type A2, and 1 case of type A3 according to 2018-AO/Orthopaedic Trauma Association (AO/OTA) fracture classification. As for the misaligned distal interlocking screw, six parameters were collected and analyzed, including the time of finding, the position, the type of passing through the cortical bone, the special circumstances during operation (such as the need to remove the intramedullary nail for reaming the diaphysis, hammering, etc.), the treatment, and the patient follow-up results.

Results

In the 9 patients, the off target of the distal interlocking screw was found in 7 cases during operation and in 2 cases after operation; the locking screw was located behind the nail in 7 cases and in front of the nail in 2 cases; the off target locking screw was passing tangentially in transcortical patern in 6 cases and in bicortical pattern through the medullary cavity in 3 cases. Three cases were attributed to the mismatch between the nail and the femur, two of which were attributed to the narrow femoral medullary cavity, one of which was attributed to the large anterolateral femoral bowing, and the other 6 cases were attributed to technical errors such as the loosening of the jig-guided targeting device, the tension of the fascia lata, and the blunt of the drill. In the 7 cases found during operation, the misaligned interlocking screw was removed first and the screw hole was left vacant, then in 2 cases, the interlocking screw was not used further; in 1 case, the distal dynamic hole was successfully inserted with a dynamic guide frame, and in 4 cases, the interlocking screw was successfully put after 2-3 attempts, leaving a large hole in the lateral cortex. No special treatment was performed in 2 cases found after operation. One patient was out of bed early after operation, 7 patients were in bed for 1 month, and 1 patient deteriorated to A3 type after operation and was in bed for 3 months. All the 9 patients were followed up 6-12 months, with an average of 8 months. Fracture healing was achieved in 8 patients. One patient with vacant interlocking screw had a secondary spiral fracture of the femoral shaft 3 months later, and was refixed with a long cephalomedullary nail and circlage wiring.

Conclusion

Distal interlocking screw off target is rare, but when it occurs, it leaves a large cortical hole in the osteoporotic femoral shaft, reducing bone strength; the use of precision instruments and attention to technical details can reduce this adverse phenomenon.

Are Sandwich Vertebrae Prone to Refracture After Percutaneous Vertebroplasty or Kyphoplasty? A Meta-Analysis

BACKGROUND

The formation of sandwiched vertebrae (SDVs) after percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) has become a common phenomenon. Whether SDVs are more likely to fracture is still controversial. Therefore, we conducted a meta-analysis to provide medical evidence for whether SDVs are more prone to refracture than non-SDVs (NSDVs) after PVP or PKP.

METHODS

This study was conducted in accordance with the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Several databases, including PubMed, Embase, Medline databases, China National Knowledge Infrastructure, Wanfang, and Weipu, were thoroughly searched for relevant studies included from any point up until June 2022. Statistical analyses were performed using Revman 5.4.

RESULTS

A total of 4052 individuals from 9 studies were enrolled. Overall, patients with SDV presented more risk to have refracture than patients with NSDV (OR = 1.57, P = 0.04). The incidences of refracture were comparable between the 2 cohorts in studies with a follow-up time less than 3 years (OR = 1.28, P = 0.49). However, patients with SDV were more prone to have refracture than patients with NSDV in studies with a follow-up time longer than 3 years (OR = 1.92, P = 0.009). Moreover, patients with SDV were more likely to have refracture than patients with NSDV in studies that involved both PVP and PKP (OR = 1.62, P = 0.002). In addition, age, low bone density, and postoperative kyphosis angle of sandwich fracture segments >10° were independent factors to predict refracture.

CONCLUSIONS

Patients with SDV were more likely to have refracture after PVP or PKP, especially when the follow-up time was longer than 3 years.

LEVEL OF EVIDENCE: 3

Risk factor analysis of refracture in the same cemented vertebra after percutaneous kyphoplasty for Kümmell's disease

OBJECTIVE

The objective of this study was to evaluate the factors that affect refracture in the same cemented vertebra after percutaneous kyphoplasty (PKP) for Kümmell's disease (KD) and establish a risk prediction score.

METHODS

A total of 2932 patients who were treated with PKP for KD between January 2019 and December 2021 were retrospectively reviewed. After inclusion and exclusion criteria were applied, 191 patients were included in the study. According to the criteria for refracture, there were 50 patients in the refracture group and 141 patients in the no-refracture group. Twenty-five factors were analyzed. Patient demographics, medical history, imaging data, surgical data, and postoperative management were reviewed. Multivariate logistic regression modeling was used to identify the independent risk factors for refracture. Receiver operating characteristic (ROC) curve analysis was used to assess and establish a risk score system and further predict the risk of refracture.

RESULTS

In this study, 50 (26.2%) patients developed a refracture. Through univariate analysis, bone mineral density (BMD) (p < 0.001), compression rate (p = 0.007), classification (i.e., the stages determined by the compression ratios) (p < 0.001), bone cement volume (p < 0.001), volume fraction (p < 0.001), distribution pattern (p = 0.007), non-PMMA endplate contact (p < 0.001), and anti-osteoporosis therapy (p < 0.001) were found to be significant factors for post-cement vertebral refracture after PKP in patients with KD. Three independent risk factors were found to be significant for refracture: small volume fraction, low BMD, and no anti-osteoporosis therapy. One point was assigned for each factor. The incidence rates of refracture in patients with scores of 0, 1, 2, and 3 were 3.7%, 4.4%, 42.0%, and 100%, respectively. The area under the ROC curve for this risk prediction score was 0.888 (p < 0.001), indicating moderate accuracy.

CONCLUSIONS

Volume fraction, BMD, and osteoporosis therapy are the main factors influencing the refracture of the same cemented vertebra in KD. On the basis of these factors, the risk prediction score developed in this paper can be used to forecast the incidence of refracture.

Surgical Correction of Post-traumatic Residual Deformity of the Mandible: A Case Report

Mandibular fractures are the most common trauma cases that we often come across in our day-to-day practice of oral and maxillofacial surgery. Various factors can lead to deformities and make those cases more challenging, which includes a delay in surgical treatment, resulting in non-union or malunion of the fracture site causing occlusal disturbances and functional abnormalities in the temporomandibular joint.

Assessing the risk of re-fracture related to the percentage of partial union in scaphoid waist fractures

Aims

There is ambiguity surrounding the degree of scaphoid union required to safely allow mobilization following scaphoid waist fracture. Premature mobilization could lead to refracture, but late mobilization may cause stiffness and delay return to normal function. This study aims to explore the risk of refracture at different stages of scaphoid waist fracture union in three common fracture patterns, using a novel finite element method.

Methods

The most common anatomical variant of the scaphoid was modelled from a CT scan of a healthy hand and wrist using 3D Slicer freeware. This model was uploaded into COMSOL Multiphysics software to enable the application of physiological enhancements. Three common waist fracture patterns were produced following the Russe classification. Each fracture had differing stages of healing, ranging from 10% to 90% partial union, with increments of 10% union assessed. A physiological force of 100 N acting on the distal pole was applied, with the risk of refracture assessed using the Von Mises stress.

Results

Overall, 90% to 30% fracture unions demonstrated a small, gradual increase in the Von Mises stress of all fracture patterns (16.0 MPa to 240.5 MPa). All fracture patterns showed a greater increase in Von Mises stress from 30% to 10% partial union (680.8 MPa to 6,288.6 MPa).

Conclusion

Previous studies have suggested 25%, 50%, and 75% partial union as sufficient for resuming hand and wrist mobilization. This study shows that 30% union is sufficient to return to normal hand and wrist function in all three fracture patterns. Both 50% and 75% union are unnecessary and increase the risk of post-fracture stiffness. This study has also demonstrated the feasibility of finite element analysis (FEA) in scaphoid waist fracture research. FEA is a sustainable method which does not require the use of finite scaphoid cadavers, hence increasing accessibility into future scaphoid waist fracture-related research.

Adjacent Fracture Rates Following Balloon Kyphoplasty in Osteoporotic Vertebral Compression Fractures: A Case Series

Background Osteoporotic vertebral compression fractures (OVCF) represent a substantial concern, as they are associated with significant increases in morbidity and mortality. One option for the management of these patients is balloon kyphoplasty, in which a balloon is inflated within the collapsed vertebral body. Following this, the cavity is filled with polymethyl methacrylate (PMMA) cement to restore height and strength. Although this procedure has been shown to have great effectiveness, one complication that has been documented is an adjacent level refracture. This is thought to be due to the increased relative strength of the repaired vertebral body. Our study aims to quantify the rates of adjacent level refracture following balloon kyphoplasty as well as identify factors that may be associated with this event. Methods  We reviewed the electronic medical records (EMR) of patients that underwent balloon kyphoplasty between January 1, 2017 and August 1, 2020. A single surgeon performed all procedures. Only adult patients who received a diagnosis of osteoporosis based on a history of fragility fracture or bone mineral density measurement were included. Patients with additional or confounding bone conditions, such as malignancy or other lytic lesions, were excluded. Data were analyzed in SPSS (IBM Corp., Armonk, NY, United States). Results We included 89 patients in our study. We observed an adjacent level refracture prevalence of 13.5% (n=12). We observed a significant increase in refracture rates among patients with unsatisfactory resolution of symptoms following initial balloon kyphoplasty, from 8.2% for satisfactory resolution of symptoms to 43.8% for those with unsatisfactory resolution. (p-value 0.011). Additionally, all 12 patients with adjacent level refractures occurred among patients with complex, multiple-level initial fracture patterns. Conclusions The treatment of OVCF with balloon kyphoplasty is a well-documented and effective method. The prevalence of adjacent-level refracture may be linked to several variables such as the initial fracture pattern. More research is needed to better predict refracture and improve patient outcomes.

Role of paraspinal muscle degeneration in the occurrence and recurrence of osteoporotic vertebral fracture: A meta-analysis

Purpose

Recently, the effects of paraspinal muscle degeneration on osteoporotic vertebral fractures (OVFs) have attracted the attention of researchers; however, studies are limited, and their results vary. Hence, this study aimed to determine the role of paraspinal muscle degeneration in the occurrence and recurrence of OVF.

Methods

Following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guideline, the PubMed, Embase, Web of Science, Wanfang Data, China National Knowledge Infrastructure, and ClinicalTrials.gov databases were comprehensively searched for relevant studies. Studies comparing the cross-sectional area (CSA) or fatty infiltration (FI) of the paraspinal muscles (including the psoas (PS), erector spinae plus multifidus (ES+MF), quadratus lumborum) in patients with and without initial OVF, or with and without recurrent OVF were included and analyzed.

Results

Eleven studies were included in the meta-analysis. Seven studies investigated the effects of paraspinal muscles on initial OVF, and the overall results revealed significantly lower CSAES+MF (SMD: -0.575, 95% CI: -0.866 to -0.285) and CSAPS (SMD: -0.750, 95% CI: -1.274 to -0.226), and higher FI (SMD: 0.768, 95% CI: 0.475 to 1.062) in the fracture group. Meanwhile, four studies evaluated the effects of the paraspinal muscles on recurrent OVF, and the pooled results demonstrated significantly higher FI (SMD:0.720, 95% CI: 0.258 to 1.182) in the refracture group, although no significant difference in CSAES+MF (SMD: -0.103, 95% CI: -0.395 to 0.189) was observed between the two groups.

Conclusions

Paraspinal muscle degeneration plays a role in the occurrence and recurrence of OVF. Assessing the paraspinal muscles may be useful for identifying high-risk populations.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier (CRD42021276681).

Bridged combined fixation system versus locking plate in the treatment of patients with implant periprosthetic refracture following proximal femoral fracture surgery: A retrospective observational study

Locking plate (LP) re-fixation is mainly used to treat postoperative implant periprosthetic refractures; however, the extensive trauma and the fixation form of LP make the operation difficult. The bridge combined fixation system (BCFS) is a new clip-rod internal fixation system, and its clinical application is in its infancy. To compare the clinical effect of BCFS and LP in the treatment of geriatric postoperative implant periprosthetic refracture following proximal femoral fracture surgery. Thirty-two patients (14 with BCFS and 18 with LP) with postoperative implant periprosthetic refracture following proximal femoral fracture surgery, who underwent surgery in our hospital, were analyzed retrospectively. The incision length, operation time, intraoperative bleeding volume, postoperative drainage volume, postoperative hospital stay, fracture healing time and complications of each patient were recorded. Regular radiographs were taken after the operation to evaluate the fracture reduction and fixation. All the patients were followed for 12 months to evaluate their limb function by Johner-Wruhs scoring criteria. The patients were followed for an average of 24.1 months, and all achieved bony union, with no complications such as infection, nonunion, and internal fixation instrument falling off and loosening after the operation. Delayed healing occurred in two cases in the LP group. The average value of surgical incision length, operation time, postoperative hospitalization time and fracture healing time in the BCFS group were significantly smaller than those in the LP group, accompanied by a decrease in intraoperative bleeding and postoperative drainage volumes (P < .05). The rate of limb function in the BCFS group (85.7%) was higher than that in the LP group (83.3%), with no significance (P > .05). The BCFS in the refracture around the implant of the proximal femoral fracture exhibited many advantages such as simple operation, strong plasticity, effective reduction of surgical trauma, promotion of fracture healing and early functional rehabilitation, etc, making it an advantageous clinical application.

Pediatric fractures following implant removal: A systematic review

OBJECTIVES

To evaluate the available literature for postoperative fracture rates following implant removal in the pediatric population.

METHODS

A systematic review of articles in the PubMed and Embase computerized literature databases from January 2000 to June 2022 was performed using PRISMA guidelines. Randomized controlled trials, case-control studies, cohort studies (retrospective and prospective), and case series involving pediatric patients that included data on fracture rate following removal of orthopedic implants were eligible for review. Two authors independently extracted data from selected studies for predefined data fields for implant type, anatomic location of the implant, indication for implantation, fracture or refracture rate following implant removal, mean time to implant removal, and mean follow-up time.

RESULTS

Fifteen studies were included for qualitative synthesis. Reported fracture rates following implant removal vary based on several factors, with an overall reported incidence of 0%-14.9%. The available literature did not offer sufficient data for conduction of a meta-analysis.

CONCLUSION

Our systematic review demonstrates that fracture following implant removal in pediatric patients is a relatively frequent complication. In children, the forearm and femur are the most commonly reported sites of fracture following removal of implants. Traumatic fractures treated definitively with external fixation have the highest reported aggregate rate of refracture. Knowledge of the incidence of this risk is important for orthopedic surgeons. There remains a need for well-designed studies and trials to further clarify the roles of the variables that contribute to this complication.

Prediction Criteria for the Formation of Refracture after Union of a Long Bone Fracture on the Basis of Hemodynamic Changes in the Tissues of the Area of Damage

We studied hemodynamic changes in the area of leg bone fracture and determined the prognostic criteria for refracture formation after achieved union. In Wistar rats (n=18), shin bone fracture with external fixation of the fragments was modeled. The union was formed 35 days after osteosynthesis, the device was removed at this term. In 5 cases, a refracture was formed after the termination of fixation. Hemodynamics and local temperature in the tissues in the area of injury were recorded before the start of the experiment and on days 21 and 35 of fixation. In rats with refracture after union, the blood circulation in the area of damage was characterized by a pronounced hypertonicity of the arteries of both large and small diameters, obstruction of venous outflow, and local hyperthermia. This hemodynamics in tissues in the area of damage can serve as an informative criterion for predicting the course of reparative osteogenesis.

Combination Treatment by Cross-Union of the Tibia and Fibula, Autogenic Iliac Bone Grafting, Reliable Fixation and Bone Morphogenetic Proteins for the Treatment of Refractory Congenital Pseudarthrosis of the Tibia

BACKGROUND

The treatment of congenital pseudarthrosis of the tibia (CPT) remains a challenge because of the difficulties of achieving and maintaining bone union, as well as complications of joint deformity and limb-length discrepancy. The purpose of this study was to evaluate the efficacy of cross-union of the tibia and fibula in achieving union and preventing refracture for patients with refractory CPT as a complementary approach to improve upon conventional surgical treatments.

METHODS

A retrospective study including patients with refractory CPT who attended our department between June 2014 and August 2020. Eighteen CPT patients, who had sustained refracture that required cast immobilization or secondary surgery, and were managed by pseudarthrosis resection, cross-union of the tibia and fibula, bone morphogenetic protein-2 and autogenous iliac bone grafting, were included. Clinical outcomes of the bone union rate and the frequency of refracture after performing cross-union of the tibia and fibula were assessed during the follow-up period.

RESULTS

The mean follow-up period was 4.3 years (range: 1.5 to 6.25 y). The mean age of the patients at surgery was 5.4 years (range: 2.6 to 10 y), and all 18 (100%) of the 18 patients had final healing at the site of pseudarthrosis. The average time spent to achieve radiologic bone union of the pseudarthrosis after operation was 2.96 months (range: 2.2 to 4.1 mo). Two (11.1%) patients had an average 2.5 cm limb-length discrepancy, none (0%) sustained refracture which needed cast immobilization or secondary surgery. Patients were all pain-free and move actively.

CONCLUSIONS

Cross-union of the tibia and fibula is a promising complementary procedure for treating refractory CPT patients.

LEVEL OF EVIDENCE

Level IV-case series.

Refracture After Removal of the PFNA in a Healed Intertrochanteric Femoral Fracture: Case Report

Hardware removal in a healed intertrochanteric fracture in elderly, which is not a routine procedure, should be needed in the case of irritable hardware. The reports of refracture after hardware removal can be seen as sparse in current literature, which are focused to secondary femoral neck fracture after removal of the lag screw or blade. We experienced a case of the intertrochanteric refracture and varus collapse after the PFNA removal in a healed fracture, treated with valgus trochanteric osteotomy and angled blade plate fixation. The PFNA is an innovative device for the treatment of the trochanteric fracture; however, the complications after removal never end. Therefore, the removal from healed fracture in elderly who have osteoporosis should not be recommended unless intractable pain had persisted.

[Comparison of refracture risk between sandwich vertebrae and ordinary adjacent vertebrae]

Objective

To compare the refracture risk between sandwich vertebrae and ordinary adjacent vertebrae, and to explore the risk factors related to refracture.

Methods

Retrospective analysis was performed on the data of patients who received percutaneous vertebral augmentation (PVA) and formed sandwich vertebrae between April 2015 and October 2019. Of them, 115 patients were enrolled in the study. There were 27 males and 88 females with an average age of 73.9 years (range, 53-89 years). Univariate analysis was performed to analyzed the patients' general data, vertebral augmentation related indexes, and sandwich vertebrae related indexes. Survival analysis was performed for all untreated vertebrae at T ₄-L ₅ of the included patients at the vertebra-specific level, and risk curves of refracture probability of untreated vertebrae between sandwich vertebrae and ordinary adjacent vertebrae were compared. Cox's proportional hazards regression model was used to analyze risk factors for refracture.

Results

The 115 patients were followed up 12.6-65.9 months (mean, 36.2 months). Thirty-seven refractures involving 51 vertebral bodies occurred in 31 patients. The refracture rate of 27.0% (31/115) in patients with sandwich vertebrae was significantly higher than that of 15.2% (187/1228) in all patients who received PVA during the same period ( χ ²=10.638, P=0.001). Univariate analysis results showed that there was a significant difference in the number of augmented vertebrae between patients with and without refractures ( Z=0.870, P=0.004). However, there was no significant difference in gender, age, body mass index, whether had clear causes of fracture, whether had dual energy X-ray absorptiometry testing, whether the sandwich vertebra generated through the same PVA, puncture method, method of PVA, number of PVA procedures, number of vertebrae with old fracture, whether complicated with spinal deformity, bone cement distribution, and kyphosis angle of sandwich vertebral area ( P>0.05). Among the 1 293 untreated vertebrae, there were 136 sandwich vertebrae and 286 ordinary adjacent vertebrae. The refracture rate of sandwich vertebrae was 11.3% which was higher than that of ordinary adjacent vertebrae (6.3%)( χ ²=4.668, P=0.031). The 1- and 5-year fracture-free probabilities were 0.90 and 0.87 for the sandwich vertebrae, and 0.95 and 0.93 for the ordinary adjacent vertebrae, respectively. There was a significant difference between the two risk curves of refracture ( χ ²=4.823, P=0.028). Cox's proportional hazards regression model analysis results showed that the sandwich vertebrae, thoracolumbar location, the number of the augmented vertebrae, and the unilateral puncture were significant risk factors for refracture ( P<0.05).

Conclusion

The sandwich vertebrae has a higher risk of refracture when compared with the ordinary adjacent vertebrae, and its 1- and 5-year fracture-free probabilities are lower than those of the ordinary adjacent vertebrae. However, the 5-year fracture-free probability of sandwich vertebrae is still 0.87, so prophylactic enhancement is not recommended for all sandwich vertebrae. In addition, the sandwich vertebrae, thoracolumbar location, the number of the augmented vertebrae, and the unilateral puncture were important risk factors for refracture.

Does dual plating clavicle fractures increase the risk of refracture after hardware removal? A biomechanical investigation

BACKGROUND

Dual orthogonal plating of midshaft clavicle fractures is increasingly used for osteosynthesis. The risk of refracture after hardware removal remains unknown. The purpose of this study was to compare the torsional and 3-point bending loads to failure of the clavicle following removal of single-plane, superior 3.5-mm plate fixation vs. dual orthogonal plating 2.7-mm constructs.

METHODS

This study used 12 pairs of clavicles (N = 24) harvested from cadaveric specimens with a mean age at death of 56.5 years (range, 46-65 years). One clavicle from each pair was randomly assigned to either superior plating (SP, n = 12) or double plating (DP, n = 12). For SP, a superior 3.5-mm plate was used as a template to drill 3 bicortical 2.8-mm holes medial and lateral to the center of the clavicle. For DP, two 2.7-mm plates were used as a template to drill 4 bicortical 2.0-mm holes medial and lateral to the center of the clavicle. Clavicle pairs were randomly and evenly distributed to undergo either 3-point bending (n = 12) or posterior torsional loading (n = 12). Cyclic loading was performed, followed by load-to-failure testing. Stiffness, displacement at failure, load to failure, and failure mode were assessed and compared between SP and DP constructs.

RESULTS

No significant differences between the SP and DP groups were observed for stiffness (768.2 ± 281.3 N/mm vs. 785.5 ± 315.0 N/mm, P = .872), displacement at failure (8.1 ± 2.8 mm vs. 5.4 ± 1.2 mm, P = .150), and ultimate load at failure (1831.0 ± 229.6 N vs. 1842.0 ± 662.4 N, P = .964) under the condition of 3-point bending. Similarly, no significant differences between the SP and DP groups were observed for torsional stiffness (1.3 ± 0.8 N · m/° vs. 1.1 ± 0.4 N · m/°, P = .844), rotation at failure (17.3° ± 4.4° vs. 14.4° ± 1.2°, P = .205), and ultimate torque at failure (14.8 ± 6.5 N · m vs. 14.7 ± 6.9 N · m, P = .103) under the condition of posterior torsional loading. The most common mode of failure for 3-point bending testing was an oblique fracture (7 of 12 clavicles, 58.3%), with no significant difference between groups (3 of 6 in SP group [50%] vs. 4 of 6 in DP group [66.7%], P > .999). The most common mode of failure with posterior torsional loading was a spiral fracture (10 of 12 clavicles, 83.3%), with no significant difference between groups (4 of 6 in SP group [66.7%] vs. 6 of 6 in DP group [100%], P = .455).

CONCLUSION

Following clavicle plate removal of either DP or SP, there is no statistically significant difference in the amount of force, under the condition of 3-point bending or torsional loading, required to fracture the diaphyseal clavicle in vitro.

The comparison of Nice knots and traditional methods as an auxiliary reduction-fixation technique in pre-contoured locking plate fixation for comminuted Robinson type 2B clavicle fracture: A retrospective study

Open reduction and pre-contoured locking plate fixation is a popular treatment option for displaced midshaft clavicle fracture. Lag screw and cerclage are 2 main intraoperative techniques to reduce and fix fragments. However, both lag screw and metallic cerclage have disadvantages. The doubled-suture Nice knot has been reported in many areas of orthopedic surgery for its effectiveness. This study aims to compare the outcomes of comminuted mid-shaft clavicle fractures reduced by Nice knots vs traditional techniques (lag screw or/and metallic cerclage) when bridged with pre-contoured locking plates.We retrospectively reviewed 101 patients (65 females and 36 males) diagnosed with midshaft clavicle fractures with at least one wedge fragment reduced by either Nice knots or traditional methods and bridged with pre-contoured locking plates between December 2016 and April 2019. Operation time, functional outcomes, pain, patient satisfaction, fracture healing, and complications were assessed at a follow-up of 12 to 40 months.The mean age of all the patients was 50.8 years. There were 52 and 49 patients in the Nice knot group and traditional group respectively, and no differences between 2 groups were found in general patient characteristics, fracture type, follow up and injury-to-surgery duration. The Nice knot group had significant less operation time (P < .01) than the traditional group (mean and standard deviation [SD], 78.6 ± 19.0 compared with 94.4 ± 29.9 minutes, respectively). For healing time, functional score, pain, satisfaction and complications, there were no significant differences between groups, despite the Nice knot group had slightly better results.Both Nice knots and traditional methods treated for comminuted Robinson type 2B clavicle fractures were effective and safe. And the Nice knots seemed to be superior with significant less operation time.

[Treatment of peri-implant refracture after intramedullary nail fixation for intertrochanteric fractures]

Objective

To investigate the occurrence, treatment, and effectiveness of peri-implant refracture after intramedullary nail fixation for intertrochanteric fractures.

Methods

The clinical data of 16 patients with peri-implant refracture after intramedullary nail fixation for intertrochanteric fractures who met the inclusion criteria between April 2014 and November 2019 were retrospectively analyzed. There were 7 males and 9 females with an average age of 78.4 years (range, 65-93 years). The 14 cases of initial intertrochanteric fractures were classified according to the classification of AO/Orthopaedic Trauma Association (AO/OTA): 5 cases of type A1, 7 cases of type A2, and 2 cases of type A3; the other 2 cases were intertrochanteric combined with subtrochanteric fractures (Seinsheimer type Ⅴ). According to the classification of peri-implant refracture which was proposed by Chan et al., there were 10 cases of type 1 (6 cases of type 1A, 3 cases of type 1B, 1 case of type 1C) and 6 cases of type 2 (4 cases of type 2A and 2 cases of type 2B). The average interval between refracture and initial surgery was 14.6 months (range, 1-52 months). The incidence of peri-implant refracture in short nail group (the length of intramedullary nail used in initial surgery≤240 mm) was 1.92% (11/573), while the incidence of long nail group (the length of intramedullary nail used in initial surgery≥340 mm) was 1.66% (5/301), showing no significant difference between the two groups ( χ ²=0.073, P=0.786). The peri-implant refractures were revised with extended intramedullary nail (5 cases) or fixed with additional limited invasive stabilization system (11 cases).

Results

The average operation time was 115.8 minutes (range, 78-168 minutes) and the average intraoperative blood loss was 283.1 mL (range, 120-500 mL). One patient died of myocardial infarction at 3 months after operation, and the other 15 patients were followed up 9-46 months (mean, 16.8 months). The peri-implant refractures healed at 14-20 weeks (mean, 16.4 weeks) after operation. There was no complications such as incision infection, nonunion, internal fixator loosening and rupture, screw cutting-out, and the second refracture during the follow-up. At last follow-up, all injured limbs regained walking function, and the Hospital for Special Surgery (HSS) score was 56-92 (mean, 80.2). The results were classified as excellent in 2 cases, good in 10, fair in 2, and poor in 1, with the excellent and good rate of 80%.

Conclusion

Stress concentration at the tip of initial intramedullary nail and distal interlocking screw aera is the main cause of peri-implant refracture after intramedullary nail fixation for intertrochanteric fractures. Revision with extended intramedullary nail or fixation with limited invasive stabilization system according to the length of initial intramedullary nail and the type of refracture can get satisfactory effectiveness.

Refracture after plate removal following ulnar shortening osteotomy for ulnar impaction syndrome - a retrospective case-control study

LEVEL OF EVIDENCE

Level III, case-control study.

[Effect of percutaneous kyphoplasty with different phases bone cement for treatment of osteoporotic vertebral compression fractures]

Objective

To compare the effect of percutaneous kyphoplasty (PKP) with different phases bone cement for treatment of osteoporotic vertebral compression fracture (OVCF).

Methods

The clinical data of 219 OVCF patients who treated with PKP and met the selection criteria between June 2016 and May 2018 were retrospectively analyzed. According to the different time of intraoperative injection of bone cement, they were divided into observation group [116 cases, intraoperative injection of polymethyl methacrylate (PMMA) bone cement in low-viscosity wet-sand phase)] and control group (103 cases, intraoperative injection of PMMA bone cement in low-viscosity wire-drawing phase). There was no significance in general date of gender, age, disease duration, body mass index, bone mineral density T value, fracture vertebral body, preoperative fracture severity of the responsible vertebral body, anterior height ratio of the responsible vertebral body, preoperative pain visual analogue scale (VAS) score, and Oswestry disability index (ODI) between the two groups ( P>0.05). The VAS score and ODI score were used to evaluate the improvement of patients' symptoms at immediate, 2 days, 3 months after operation and at last follow-up. At 1 day, 3 months after operation, and at last follow-up, X-ray film and CT of spine were reexamined to observe the distribution of bone cement in the vertebral body, bone cement leakage, and other complications. During the follow-up, the refracture rate of the responsible vertebral body and the fracture rate of the adjacent vertebral body were recorded.

Results

The injection amount of bone cement in the observation group and control group were (4.53±0.45) mL and (4.49±0.57) mL, respectively, showing no significant difference between the two groups ( t=1.018, P=0.310). Patients in both groups were followed up 6-18 months (mean, 13.3 months). There were 95 cases (81.9%) and 72 cases (69.9%) of the bone cement distribution range more than 49% of the cross-sectional area of the vertebral body in the observation group and the control group, respectively, showing significant difference in the incidence between the two groups ( χ ²=4.334, P=0.037). The VAS score and ODI score of the postoperative time points were significantly improved compared with those before operation ( P<0.05), and there were significant differences among the postoperative time points ( P<0.05). The VAS score and ODI score of the observation group were significantly better than those of the control group ( P<0.05) at immediate, 2 days, and 3 months after operation, and there was no significant difference between the two groups at last follow-up ( P>0.05). At 1 day after operation, the cement leakage occurred in 18 cases of the observation group (8 cases of venous leakage, 6 cases of paravertebral leakage, 4 cases of intradiscal leakage) and in 22 cases of the control group (9 cases of venous leakage, 8 cases of paravertebral leakage, 5 cases of intradiscal leakage). There was no significant difference between the two groups ( P>0.05). During the follow-up, 5 cases (4.3%) in the observation group, 12 cases (11.7%) in the control group had responsible vertebral refracture, and 6 cases (5.2%) in the observation group and 14 cases (13.6%) in the control group had adjacent vertebral fracture, the differences were significant ( χ ²=4.105, P=0.043; χ ²=4.661, P=0.031).

Conclusion

Bone cement injection with wet-sand phase in PKP is beneficial for the bone cement evenly distributed, strengthening the responsible vertebral, relieving the short-term pain after operation, decreasing the rate of responsible vertebral refracture and adjacent vertebral fracture without increasing the incidence of relevant complications and can enhance the effectiveness.

Is Refracture a Concern Following Closed Management of Tibia Shaft Fractures in Children?

PURPOSE

Tibia shaft fractures account for 15% of all pediatric fractures. These fractures are often treated nonoperatively with closed reduction and long leg casting. In children treated nonoperatively, refracture can cause significant frustration to both the patient and their family in addition to a delay in resuming normal activities for several months. The purpose of this study was to investigate the rate of refracture of tibia shaft fractures treated nonoperatively at our institution.

METHODS

We performed a retrospective chart review of pediatric patients at one institution with the diagnosis of a tibia shaft fracture who were treated nonoperatively between January 1, 2000 and December 31, 2016. Exclusion criteria included those without complete retrievable radiographs or without radiographic confirmation of healed fracture. Patients who sustained a proximal or distal metaphysical tibia fracture or a toddler fracture were also excluded. Additionally, those with less than three months of clinic follow-up or an underlying metabolic bone disease were excluded. Data such as age, sex, body mass index, mechanism of injury, location of fracture, initial displacement, angulation, treatment, length of immobilization, and complications were recorded. The primary outcome for our study was the presence of refracture. Refracture was defined as a repeat fracture of the tibia at the same location within 18 months of the original fracture.

RESULTS

A total of 64 patients met the inclusion criteria and were included in the study. Of the 64 patients, only one patient sustained a refracture. The refracture occurred eight months after the initial injury and required operative intervention. This rate of refracture is equated to roughly 1.5%.

CONCLUSION

Conservative management of closed tibia shaft fractures with casting is an ideal treatment for pediatric fractures. Conservative management allows for avoidance of surgical intervention and low refracture rates. This study provides support regarding the adequacy of conservative management with limited complications. Although the rate of refracture still exists, patients and families should be counseled that the rate of healing without complications is about 98.5%.

Pediatric Forearm Refracture with Intramedullary Nail Bending In Situ: Options for Treatment

In this study, we present the case of a nine-year-old male patient who had initially presented to the emergency department with a right both-bone forearm fracture. He was treated with closed reduction and long-arm casting. The cast was applied for six weeks and then replaced with a short-arm cast for two weeks. The patient returned with a both-bone forearm refracture one and a half months after the removal of the cast. Surgical treatment was initiated and an intramedullary nail fixation was applied. The patient sustained a new trauma five months postoperatively. The condition was diagnosed to be a refracture of the both-bone forearm with an intramedullary nail in situ. Closed reduction was performed, but an acceptable level of reduction was not achieved. Subsequently, intramedullary nails were replaced with new nails. At the one year follow-up, the patient was observed to have a full range of motion and reported no pain or muscle weakness.

Incidence and Mortality of Osteoporotic Refractures in Korea according to Nationwide Claims Data

PURPOSE

Studies on the incidence and mortality of refractures after primary osteoporotic fracture are limited by the relatively rare incidence of such refractures and small sample sizes. The objectives of this research were: 1) to determine the incidence of osteoporotic refractures and fracture locations and 2) to assess mortality rates associated with osteoporotic refracture over a median follow up of 3 years using nationwide claim database.

MATERIALS AND METHODS

Patients over 50 years of age who had an osteoporotic fracture that was confirmed operationally were enrolled. Refracture was defined as that after 6 months of an untreated period. Mortality rate was calculated using the Charlson comorbidity index and was analyzed using Cox proportional hazards regression analysis.

RESULTS

A total of 18956 first-time instances of osteoporotic fracture were reported between 2007 and 2012 after a median follow up of 3.1 years (range, 1 to 7 years). Among 18956 patients, 2941 (15.50%) experienced refracture. After follow up for 1 year, cumulative mortality rates for re-fracture and non-refracture groups were 9.1% and 7.2%, respectively. After adjusting for covriates, mortality rate was 1.2 times greater in patients with re-fracture than in patients without re-fracture over a median follow up of 3 years (hazard ratio: 1.20, 95% confidence interval: 1.08-1.34, p<0.001).

CONCLUSION

The incidence of osteoporotic re-fracture in this nationwide study was 15.5%, and the mortality rate of re-fracture patients was 1.2 times higher than that of non-refracture patients over a median follow up of 3 years.

Rates of osteoporosis screening and treatment following vertebral fracture

BACKGROUND CONTEXT

Osteoporosis remains an underrecognized and undertreated disease entity in the orthopaedic setting, accounting for substantial long-term morbidity and mortality. Osteoporosis is often not diagnosed or treated until multiple fractures have occurred. Vertebral compression fractures are the most common sentinel fracture, providing an opportunity to intervene with antiresorptive therapy before more debilitating fractures occur. Little data has been published on osteoporosis screening and treatment following vertebral fractures. Further elucidation of the osteoporosis care gap in these patients is warranted.

PURPOSE

To demonstrate the current state of post vertebral fracture osteoporosis management at a large tertiary care center with no established secondary fracture prevention program.

STUDY DESIGN

Retrospective cohort study.

SETTING

A large tertiary care hospital or one of its affiliated community hospitals.

PATIENT SAMPLE

All 2,933 patients, 50 years of age or older, who presented to an emergency department with a new vertebral fracture between 2008 and 2014.

OUTCOME MEASURES

The physiological measures are rates of new fractures within 2 years following first vertebral fracture.

PATIENT CARE METRICS

Post vertebral fracture rates of dual energy X-ray absorptiometry (DXA) testing, calcium and vitamin D supplementation, and pharmacotherapy for osteoporosis within 1 year postfracture, and more than 1 year postfracture. Linear trend of the rate of new antiosteoporosis pharmacotherapy among previously antiosteoporosis medication naive patients within 1 year of fracture over time from 2008 to 2014.

METHODS

All patients aged 50 years or older presenting to an emergency department with a vertebral fracture between 2008 and 2014 were included. Only an individual's first documented vertebral fracture was considered. Individuals were assessed for DXA screening, calcium and vitamin D supplementation, treatment with an antiosteoporosis medication, and additional fractures following incident vertebral fracture. Statistical analyses included descriptive statistics and a simple logistic regression. No specific funding was provided for this study. The authors of this study report no relevant financial conflicts of interests or associated biases.

RESULTS

Between 2008 and 2014, 2,933 unique patients were seen at an included emergency department for one or more vertebral fracture encounters. Ninety-eight percent did not receive a DXA scan within the preceding 2 years or 1 year following fracture. Seven percent of patients were started on antiresorptive therapy after their fracture, with 341 (5%) starting within 1 year of fracture and 211 (2%) starting thereafter. Twenty-one percent (n=616) had taken an antiresorptive medication before their fracture. Seventy three percent (n=2,128) were never prescribed antiresorptive therapy. Treatment rates slightly decreased over time. Thirty eight percent of patients presenting with a vertebral fracture (n=1,115) went on to develop a second fragility fracture within 2 years.

CONCLUSIONS

In the absence of a specific local program to improve secondary fracture prevention following minimal trauma spinal fractures, recognition and treatment of osteoporosis in patients at this institution remained dismal over time despite numerous calls to action on the topic in the orthopaedic literature and elsewhere. Undertreatment of osteoporosis puts patients at increased risk of incurring additional fractures. Within 2 years, 38% of the patients in this sample developed an additional fragility fracture. This study demonstrates a profound post vertebral fracture osteoporosis care gap.

Results of Rodding and Impact on Ambulation and Refracture in Osteogenesis Imperfecta: Study of 21 Children

INTRODUCTION

Delay in presentation and surgical intervention is quite usual in osteogenesis imperfecta (OI) because of various local and cultural beliefs. The purpose of this study is to review the results of 21 children who had intramedullary rodding and its effect on ambulation and refracture.

METHODS

We reviewed 21 children with a clinical diagnosis of OI. The mean age of children at presentation was 8.74 years (3-21 years). All children had recurrent fractures of long bones. Twenty eight femurs and 21 tibiae were stabilized with intramedullary rodding. Ambulatory status was assessed by the Hoffers and Bullock's (H and B) grading, and muscle power was recorded using the Medical Research Council, U. K., grade. Ten children had received intravenous bisphosphonates preoperatively. Postoperatively, the children were assessed for ambulatory status, pain, and ability for independent self-care.

RESULTS

The mean followup period was 34 months (24-48 months). Rush rods were used in 20 femurs, the Fassier-Duval (FD) rods in 6 femurs, and in two cases, with narrow intramedullary canals, Kirshner (K) wires were used. For the tibiae, 15 children received rush rods and in 6 cases, an FD rod was used. The mean time to fracture union was 8 weeks (6-12 weeks). Before surgery, 13 children were in H and B Grade 4 (wheel-chair independent or carried by parents usually in a developing country), four were able to ambulate with a walking aid (H and B Grade 3b), and four children were able to walk about in the house without aids (H & B Grade 2). After the rodding procedure, the ambulatoty status improved in 11 (50%) children. Seven children (33%) became household physiologic walkers (H & B Grade 3b), three achieved independent ambulation with orthosis (H & B Grade 1b), and one child with mild OI could walk unaided (H & B Grade 1a). No child had deterioration in ambulatory status. Only two children had refractures at the distal end of the rod due to continual growth of bones.

CONCLUSIONS

Intramedullary rodding treatment for recurrent fractures in children with OI improves their mobility potential. It also and prevents repeated cast application, disuse wasting, and osteopenia which can lead to deterioration in the quality of the long bones.

Prior fracture and refracture among patients admitted with hip fracture: Data from a regional hip fracture registry in Sri Lanka

AIM

Fragility hip fracture has become a major global health concern. Data related to recurrent fragility fractures are sparse in the South Asian region.

METHOD

We assessed the prevalence of prior fragility fracture among patients admitted with new hip fracture to a tertiary care hospital in southern Sri Lanka. Also the incidence of refracture was assessed among hip fracture survivors followed up for 24 months after discharge.

RESULTS

Three hundred and nine patients with incident hip fracture were admitted during the study period (June 2014-February 2015) and 11 patients died while in the ward. We detected previous fracture in the contralateral hip in eight patients, while two others had distal radius fracture and one patient clinical vertebral fracture (rate = 3.6%). During the follow up two patients developed fractures in the contralateral hip while either clinical vertebral or distal forearm fractures were not detected (refracture rate = 0.004/person years).

CONCLUSION

This analysis based on a regional hip fracture registry shows a low prevalence of prior fracture among patients admitted with incident hip fracture and a low rate of refracture among survivors. More studies are needed to assess whether there are geographical variations in the prevalence of prior fracture or refracture among patients with incident hip fracture.

Refracture of osteoporotic vertebral body after treatment by balloon kyphoplasty: Three cases report

RATIONALE

Balloon kyphoplasty is a widely accepted treatment of osteoporotic vertebral compression fractures (OVCFs) with good results and a low risk for complications. A refracture of previously treated vertebra is a relatively rare condition.

PATIENT CONCERNS

We reported our 3 cases and reviewed all relevant literatures of 11 cases with refracture of osteoporotic vertebral body after kyphoplasty.

DIAGNOSES

Follow-up radiographs or magnetic resonance imaging examination confirmed refractures of previously treated vertebrae after kyphoplasty.

INTERVENTIONS

One patient with 1 refracture of osteoporotic vertebral body after kyphoplasty was treated conservatively, but the other 2 patients were treated surgically because of multiple vertebral fractures or neurological deficits.

OUTCOMES

The average age of the patients was 76.8 years (range, 63-86 years). All the patients had severe osteoporosis with a mean T-score of -3.46 (range -5.0 to -3.0). The sites of refractures are in the lumbar and thoracolumbar regions. Severe osteoporosis, the presence of intravertebral cleft, and a solid lump injection pattern of polymethylmethacrylate would result in insufficient strengthening effects of cement augmentation and therefore increased the likelihood of refractures of the kyphoplasty vertibrae.

LESSONS

Patients with OVCFs and intravertebral cleft who did not obtain complete pain-relief at the treated vertebral level after kyphoplasty should be strictly followed up. Early finding of this condition and rapid intervention might contribute to avoiding the occurrence of the cemented vertebral refracture after kyphoplasty. Conservative treatments such as back brace and antiosteoporotic medications were strongly recommended.

Prevention of osteoporotic refractures in regional Australia

OBJECTIVE

Clinical guidelines recommend that patients who sustain a minimal trauma fracture (MTF) should receive a bone mineral density (BMD) scan and bisphosphonate (or equivalent) therapy if diagnosed with osteoporosis. A pilot fracture liaison service (FLS) was implemented in regional NSW to improve adherence to the guidelines.

DESIGN

Prospective cohort study with an historical control.

SETTING

Primary care.

PARTICIPANTS

Control (n = 47) and cohort (n = 93) groups comprised patients consenting to interview who presented with a MTF to the major referral hospital 4 months before and 12 months after FLS implementation respectively.

MAIN OUTCOME MEASURES

Primary outcome measures were the rates of BMD scans and anti-osteoporotic medication initiation/review after MTF. Hospital admission data were also examined to determine death and refracture rates for all patients presenting during the study period with a primary diagnosis of MTF within 3 years of their initial fracture.

RESULTS

Although there was no improvement in BMD scanning rates, the reported rate of medication initiation/review after fracture was significantly higher (P < 0.05) in the FLS cohort. However, once adjusted for age, this association was not significant (P = 0.086). There was a lower refracture rate during the cohort period (P = 0.013), however, there were significantly more deaths (P = 0.035) within 3 years of initial fracture. When deaths were taken into account via competing risk regression, patients in the cohort period were significantly less likely to refracture than those in the control period (Hazard ratio = 0.576, P = 0.032).

CONCLUSIONS

A rurally based nurse-led FLS was associated with modest improvement after MTF. Consideration should be given to ways to strengthen the model of care to improve outcomes.

Operative Treatment of Fifth Metatarsal Jones Fractures (Zones II and III) in the NBA

BACKGROUND

Proximal fractures of the fifth metatarsal (zone II and III) are common in the elite athlete and can be difficult to treat because of a tendency toward delayed union, nonunion, or refracture. The purpose of this case series was to report our experience in treating 10 NBA players, determine the healing rate, return to play, refracture rate, and role of foot type in these athletes.

METHODS

The records of 10 professional basketball players were retrospectively reviewed. Seven athletes underwent standard percutaneous internal fixation with bone marrow aspirate concentrate (BMAC) whereas the other 3 had open bone grafting primarily in addition to fixation and BMAC. Radiographic features evaluated included fourth-fifth intermetatarsal, fifth metatarsal lateral deviation, calcaneal pitch, and metatarsus adductus angles.

RESULTS

Radiographic healing was observed at an overall average of 7.5 weeks and return to play was 9.8 weeks. Three athletes experienced refractures. There were no significant differences in clinical features or radiographic measurements except that the refracture group had the highest metatatarsus adductus angles. Most athletes were pes planus and 9 of 10 had a bony prominence under the fifth metatarsal styloid.

CONCLUSION

This is the largest published series of operatively treated professional basketball players who exemplify a specific patient population at high risk for fifth metatarsal fracture. These players were large and possessed a unique foot type that seemed to be associated with increased risk of fifth metatarsal fracture and refracture. This foot type had forefoot metatarsus adductus and a fifth metatarsal that was curved with a prominent base. We continue to use standard internal fixation with bone marrow aspirate but advocate additional prophylactic open bone grafting in patients with high fourth-to-fifth intermetatarsal, fifth metatarsal lateral deviation, and metatarsus adductus angles as well as prominent fifth metatarsal styloids in order to improve fracture healing and potentially decrease the risk of refracture.

LEVEL OF EVIDENCE

Level IV, case series.

Scaphoid Proximal Pole Fracture Following Headless Screw Fixation

Background Headless screw fixation of scaphoid fractures and nonunions yields predictably excellent outcomes with a relatively low complication profile. However, intramedullary implants affect the load to failure and stress distribution within bone and may be implicated in subsequent fracture. Case Description We describe a posttraumatic fracture pattern of the scaphoid proximal pole originating at the previous headless screw insertion site in three young male patients with healed scaphoid nonunions. Each fracture was remarkably similar in shape and size, comprised the volar proximal pole, and was contiguous with the screw entry point. Treatment was challenging but successful in all cases. Literature Review Previous reports have posited that stress-raisers secondary to screw orientation may be implicated in subsequent peri-implant fracture of the femoral neck. Repeat scaphoid fracture after screw fixation has also been reported. However, the shape and locality of secondary fracture have not been described, nor has the potential role of screw fixation in the production of distinct fracture patterns. Clinical Relevance Hand surgeons must be aware of this difficult complication that may follow antegrade headless screw fixation of scaphoid fracture nonunion, and of available treatment strategies.

Factors associated with recurrent fifth metatarsal stress fracture

BACKGROUND

Many surgeons agree that fifth metatarsal stress fractures have a tendency toward delayed union, nonunion, and possibly refracture. Difficulty healing seems to be correlated with fracture classification. However, refracture sometimes occurs after low-grade fracture, even long after apparent resolution.

METHODS

The records of 168 consecutive cases of fifth metatarsal stress fracture (163 patients) treated by modified tension band wiring from March 2002 to June 2011 were evaluated retrospectively. Mean length of follow-up was 23.6 months (range, 10-112 months). Forty-nine cases classified as Torg III were bone grafted initially also. All enrolled patients were elite athletes. Eleven patients experienced nonunion and 18 refracture. The 11 nonunion cases were bone grafted. The 157 patients (excluding nonunion cases) were allocated to either a refracture group or a union group. Clinical features, such as age, weight, fracture classification, time to union, and reinjury history, were compared. Radiological parameters representing cavus deformity and fifth metatarsal head protrusion were compared to evaluate the influence of structural abnormalities.

RESULTS

Mean group weights were significantly different (P = .041), but mean ages (P = .879), fracture grades (P = .216, P = .962), and time from surgery to rehabilitation (P = .539) were similar. No significant intergroup differences were found for talocalcaneal (TC) angle (P = .470), calcaneal pitch (CP) angle (P = .847), or talo-first metatarsal (T-MT1) angle (P = .407) on lateral radiographs; for fifth metatarsal lateral deviation (MT5-LD) angle (P = .623) on anteroposterior (AP) radiographs; or for MT5-LD angle (P = .065) on the 30-degree medial oblique radiographs. However, the mean fourth-fifth intermetatarsal (IMA4-5) angle on AP radiographs was significantly greater in the refracture group, and for Torg II cases, mean weight (P = .042), IMA4-5 angle on AP radiographs (P = .014), and MT5-LD angle (P = .043) on 30-degree medial oblique radiographs were significantly greater in the refracture group. For B2 cases (incomplete fracture and a plantar gap of 1 mm or larger), mean weight (P = .046), IMA4-5 angle on AP radiographs (P = .019), and MT5-LD angle (P = .045) on 30-degree medial oblique radiographs were significantly greater in the refracture group. All cases of refracture had a traumatic history after bone union. Refracture developed within 6 months of starting rehabilitation in 13 cases and within 3 months in 8 cases.

CONCLUSION

The development of refracture after the surgical treatment of fifth metatarsal stress fractures was found to be associated with higher body mass index (BMI) and with radiological parameters (IMA4-5 on AP radiographs, MT5-LD on oblique radiographs) associated with protrusion of the fifth metatarsal head. The study indicates that patients with a protruding fifth metatarsal head and a high BMI should approach rehabilitation with care before considering a return to previous sporting activity levels.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

The second hip fracture in osteoporotic patients: not only an orthopaedic matter

The second hip fracture indicates the fracture of the osteoporotic femoral neck which occurs in patients already operated on the opposite side. It is a growing problem, especially in Italy where the ageing rate of the population is one of the highest in the world. Only in recent years this issue has been discussed in the international literature about timing and the treatment methods as a consequence linked to the social costs, mortality, disability of this pathology. The aim of our study is the evaluation of the incidence of hip fractures in a sample of patients that already substained a surgical procedure for a proximal femour fracture. The evaluation was based on the time elapsed between the two fractures, the quality of life after the second fractural episode through a telephone questionnaire (EQ-5D), the incidence of mortality, the adhesion to the antifractural therapy and the comparison of the obtained data to the international standards.

Repeat vertebroplasty for the subsequent refracture of procedured vertebra

Vertebroplasty (VP) can effectively treat pain and immobility caused by vertebral compression fracture. Because of complications such as extravasation of bone cement (polymethylmethacrylate, PMMA) and adjacent vertebral fractures, some practitioners prefer to inject a small volume of PMMA. In that case, however, insufficient augmentation or a subsequent refracture of the treated vertebrae can occur. A 65-year-old woman visited our clinic complaining of unrelieved severe low back and bilateral flank pain even after she had undergone VP on the 1(st) and 4(th) (L1 and L4) lumbar vertebrae a month earlier. Radiologic findings showed the refracture of L1. We successfully performed the repeat VP by filling the vertebra with a sufficient volume of PMMA, and no complications occurred. The patient's pain and immobility resolved completely three days after the procedure and she remained symptom-free a month later. In conclusion, VP with small volume cement impaction may fail to relieve fracture-induced symptoms, and the refracture of an augmented vertebral body may occur. In this case, repeat VP can effectively resolve both the persistent symptoms and problems of new onset resulting from refracture of the augmented vertebral body due to insufficient volume of bone cement.

Refractures of the upper extremity in children

PURPOSE

To investigate the etiologic factors related to refractures of the upper extremity in children.

PATIENTS AND METHODS

Eighteen refractures were divided into three groups according to the location of the initial fractures. They were analyzed in terms of the type of refractures, fracture patterns, and the existence of an underlying deformity.

RESULTS

Of nine supracondylar fractures of the humerus, two involved refractures at the supracondylar region, and the other seven involved the lateral condyle. Underlying cubitus varus was present in six cases. Of three lateral condylar fractures of the humerus, one had a refracture at the supracondylar region, and two cases involved the lateral condyle. One had an underlying cubitus varus. All but one case in the humeral fractures group were late refractures, and were treated with surgery. Of six repeat forearm fractures, five were early type and occurred at the original site within nine weeks, four at the diaphysis of both bones of the forearm, and one at the diaphysis of the ulna. All cases in the forearm fractures group, save one, had volar angulation before the refracture, and were treated conservatively.

CONCLUSION

In the humerus, the underlying cubitus varus was the most important predisposing factor for refractures and lateral condyle fractures were common. In the forearm, volar angulation of the diaphysis was related to refractures, and complete and circular consolidation of the primary fracture of the forearm was thought to be important in prevention.