Aims. Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone. Methods. Overall, 31 patients with AO/OTA 31-A2 trochanteric fractures were randomized to either a SHS alone or a SHS with an additional TSP. To compare postoperative fracture motion, radiostereometric analysis (RSA) was performed before and after weightbearing, and then at four, eight, 12, 26, and 52 weeks. With the “after weightbearing” images as baseline, we calculated translations and rotations, including shortening and medialization of the femoral shaft. Results. Similar migration profiles were observed in all directions during the course of healing. At one year, eight patients in the SHS group and 12 patients in the TSP group were available for analysis, finding a clinically non-relevant, and statistically non-significant, difference in total translation of 1 mm (95% confidence interval -4.7 to 2.9) in favour of the TSP group. In line with the migration data, no significant differences in clinical outcomes were found. Conclusion. The TSP did not influence the course of healing or postoperative fracture motion compared to SHS alone. Based on our results, routine use of the TSP in AO/OTA 31-A2 trochanteric fractures cannot be recommended. The TSP has been shown, in biomechanical studies, to increase stability in sliding hip screw constructs in both unstable and intermediate stable trochanteric fractures, but the clinical evidence is limited. This study showed no advantage of the TSP in unstable (AO 31-A2) fractures in elderly patients when fracture movement was evaluated with radiostereometric analysis. Cite this article: Bone Jt Open 2024;5(1):37–45

Aims. This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days. Methods. We analyzed data from 26,393 patients with trochanteric AO/OTA A1 and A2 fractures treated with IMNs (n = 9,095) or SHSs (n = 17,298) in the Norwegian Hip Fracture Register (January 2008 to December 2020). Exclusions were made for patients aged < 60 years, pathological fractures, pre-2008 operations, contralateral hip fractures, fractures other than trochanteric A1/A2, and treatments other than IMNs or SHSs. Kaplan-Meier and Cox regression analyses adjusted for type of fracture, age, sex, cognitive impairment, American Society of Anesthesiologists (ASA) grade, and time period were conducted, along with calculations for number needed to harm (NNH). Results. In unadjusted analyses, there was no significant difference between IMN and SHS patient survival at 30 days (91.8% vs 91.1%; p = 0.083) or 90 days (85.4% vs 84.5%; p = 0.065), but higher one-year survival for IMNs (74.5% vs 73.3%; p = 0.031) compared with SHSs. After adjustments, no significant difference in 30-day mortality was found (hazard rate ratio (HRR) 0.94 (95% confidence interval (CI) 0.86 to 1.02(; p = 0.146). IMNs exhibited higher mortality at 0 to 1 days (HRR 1.63 (95% CI 1.13 to 2.34); p = 0.009) compared with SHSs, with a NNH of 556, but lower mortality at 8 to 30 days (HRR 0.89 (95% CI 0.80 to 1.00); p = 0.043). No differences were observed in mortality at 2 to 7 days (HRR 0.94 (95% CI 0.79 to 1.11); p = 0.434), 90 days (HRR 0.95 (95% CI 0.89 to 1.02); p = 0.177), or 365 days (HRR 0.97 (95% CI 0.92 to 1.02); p = 0.192). Conclusion. This study found no difference in 30-day mortality between IMNs and SHSs. However, IMNs were associated with a higher mortality at 0 to 1 days and a marginally lower mortality at 8 to 30 days compared with SHSs. The observed differences in mortality were small and should probably not guide choice of treatment. Cite this article: Bone Joint J 2024;106-B(6):603–612

We evaluated the impact of stereo-visualisation of three-dimensional volume-rendering CT datasets on the inter- and intraobserver reliability assessed by kappa values on the AO/OTA and Neer classifications in the assessment of proximal humeral fractures. Four independent observers classified 40 fractures according to the AO/OTA and Neer classifications using plain radiographs, two-dimensional CT scans and with stereo-visualised three-dimensional volume-rendering reconstructions. Both classification systems showed moderate interobserver reliability with plain radiographs and two-dimensional CT scans. Three-dimensional volume-rendered CT scans improved the interobserver reliability of both systems to good. Intraobserver reliability was moderate for both classifications when assessed by plain radiographs. Stereo visualisation of three-dimensional volume rendering improved intraobserver reliability to good for the AO/OTA method and to excellent for the Neer classification. These data support our opinion that stereo visualisation of three-dimensional volume-rendering datasets is of value when analysing and classifying complex fractures of the proximal humerus

Purpose: To evaluate the intra and inter-observer variation of the Schatzker and AO/OTA classifications in assessing tibial plateau fractures, using plain radiographs. Summary: Fifty tibial plateau fractures were classified independently by 6 observers as per the Schatzker and AO/OTA classifications, using antero-posterior and lateral plain radiographs. Assessment was done on two occasions 8 weeks apart. We found that both the Schatzker and AO/OTA classifications have a high intra-observer (kappa=0.57 and 0.53 respectively), and inter-observer (kappa=0.41 and 0.43 respectively) variation. Classification of tibial plateau fractures into unicondylar vs. bicondylar and pure splits vs. articular depression +/− split conferred improved inter and intra-observer variation. Conclusions: The high inter-observer variation found for the Schatzker and AO/OTA classifications must be taken into consideration when these are used as a guidance of treatment and when used in evaluating patients’ outcome. Simply classifying tibial plateau fractures into unicondylar vs. bicondylar and pure splits vs. articular depression +/− split may be more reliable

Background. Current literature of definition, classification and outcomes of fractures of talar body remains controversial. Our primary purpose is to present an unusual combination of fractures of talar body with pantalar involvement / dislocation / extension as a basis for modification of Müller AO / OTA Classification. Methods. We include four consecutive patients, who sustained talar body fractures with pantalar subluxation/dislocation /extension. These unusual injury patterns lead us to reconsider Müller AO / OTA Classification in the light of another widely used talar fracture classification, Hawkins Classification of fractures of neck of talus and subsequent modification by Canale and Kelly. Results. Müller AO / OTA Classification comprises CI – Ankle joint involvement, C2 – Subtalar joint involvement, C3 – Ankle and subtalar joint involvement. We propose Modification of Müller AO / OTA. Classification. C1 – Absolutely undisplaced fracture; C2 – Ankle and Subtalar joint involvement: subluxation; C3 – Ankle and subtalar joint involvement: subluxation with comminution; C4 – Ankle, subtalar and talonavicular joint involvement. Conclusions. Our modification redefines Müller AO / OTA Classification, extends and fills the void in the classification by inclusion of C4, draws attention to stability of talonavicular joint and reflects increasing severity of injury in fractures of talar body

Aims. To investigate if preoperative CT improves detection of unstable trochanteric hip fractures. Methods. A single-centre prospective study was conducted. Patients aged 65 years or older with trochanteric hip fractures admitted to Stavanger University Hospital (Stavanger, Norway) were consecutively included from September 2020 to January 2022. Radiographs and CT images of the fractures were obtained, and surgeons made individual assessments of the fractures based on these. The assessment was conducted according to a systematic protocol including three classification systems (AO/Orthopaedic Trauma Association (OTA), Evans Jensen (EVJ), and Nakano) and questions addressing specific fracture patterns. An expert group provided a gold-standard assessment based on the CT images. Sensitivities and specificities of surgeons’ assessments were estimated and compared in regression models with correlations for the same patients. Intra- and inter-rater reliability were presented as Cohen’s kappa and Gwet’s agreement coefficient (AC1). Results. We included 120 fractures in 119 patients. Compared to radiographs, CT increased the sensitivity of detecting unstable trochanteric fractures from 63% to 70% (p = 0.028) and from 70% to 76% (p = 0.004) using AO/OTA and EVJ, respectively. Compared to radiographs alone, CT increased the sensitivity of detecting a large posterolateral trochanter major fragment or a comminuted trochanter major fragment from 63% to 76% (p = 0.002) and from 38% to 55% (p < 0.001), respectively. CT improved intra-rater reliability for stability assessment using EVJ (AC1 0.68 to 0.78; p = 0.049) and for detecting a large posterolateral trochanter major fragment (AC1 0.42 to 0.57; p = 0.031). Conclusion. A preoperative CT of trochanteric fractures increased detection of unstable fractures using the AO/OTA and EVJ classification systems. Compared to radiographs, CT improved intra-rater reliability when assessing fracture stability and detecting large posterolateral trochanter major fragments. Cite this article: Bone Jt Open 2024;5(6):524–531

Introduction: The AO/OTA 31 A-3 fractures are very unstable and biomechanically differ from the 31 A-1 and A-2 fractures. Recent papers state that the extra-medullary implants used to treat these fractures have a failure rate as high as 56%. Few papers report the results with intramedullary implants, and, sometimes to heal the fracture, the nails had to be dynamised by to removing the distal screw or the fracture is “self-dyna-mised” by breaking the distal screw. Material and Methods: A prospective clinical study was designed to treat 57 consecutive patients with a 31 A-3 fracture. Mean age (84.2 years). The GT Short Nail (17-cm long, 16-mm upper diameter, and a distal locking oval hole allowing 12 mm of proximal sliding), was inserted through the apex of the greater trochanter to stabilize these fractures with a single 9-mm rotationally unlocked hip-screw, and a distal dynamically locked screw. 43 patients followed for six months were included in the study. Radiological studies: screw-tip migration (Doppelt’s method), hip-screw sliding, tip-apex distance (Baumgaertner), and proximal sliding of the distal locking screw (intra-op, one week, one month, three and six months). Full weight bearing with the needed help was encouraged as soon as possible. Results: All fractures but one, healed uneventfully. No cutouts, no thigh pain, 1 implant failure in the only delayed healing case, and no deep infections. Three patients had further surgery to heal a bleeding skin incision. The failed implant was removed and replaced by a 90° Synthes hip plate. The average tip-screw migration was 2.4 mm, the tip-apex-distance was < than 25 mm in 94% of the cases, the average hip-screw sliding was 6.4 mm, and the average proximal sliding of the distal locking screw was 4.9 mm. In 24.5 % of the cases (14) the proximal sliding of the distal dynamically locked screw was over 10 mm. Conclusions: A single 9-mm diameter rotationally unlocked hip screw works very well through the healing process of these very unstable fractures. A dynamically distal locked screw controls the femoral shaft rotation. Our study shows that the distal locking hole of the trochanteric nails should allow at least 10 mm of proximal sliding to provide the unknown needed proximal sliding of the distal fragment to minimize delayed or non-healing of these fractures

Background

Open reduction and internal fixation using plate osteosynthesis for midshaft clavicle fractures is often associated with hardware prominance. Although clinical studies have suggested a role for the use of thinner 2.7mm plates as a means of increasing cosmetic acceptability this still remains an area of controversy. We investigated the effect of plate size (2.7mm vs. 3.5mm), plate treatment (annealed vs. cold worked) and number of screws on the stiffness and yield point.

Controversy exists whether to treat unstable pertrochanteric hip fractures with either intra-medullary or extra-medullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw or long Gamma Nail. The hypothesis was that there is no difference in outcome between the two modes of treatment.

Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2) were recruited into the study. Eligible patients were randomised on admission to either long Gamma Nail or sliding hip screw. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure or ‘cut-out’. Secondary measures included mortality, length of hospital stay, transfusion rate, change in mobility and residence, and EuroQol outcome score.

Five patients required revision surgery for implant cut-out (2.5%), of which three were long Gamma Nails and two were sliding hip screws (no significant difference). There were no incidences of implant failure or deep infection. Tip apex distance was found to correlate with implant cut-out. There was no statistically significant difference in either the EuroQol outcome scores or mortality rates between the two groups when corrected for mini mental score. There was no difference in transfusion rates, length of hospital stay, and change in mobility or residence. There was a clear cost difference between the implants.

The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur.

Aims. This study evaluates risk factors influencing fracture characteristics for postoperative periprosthetic femoral fractures (PFFs) around cemented stems in total hip arthroplasty. Methods. Data were collected for PFF patients admitted to eight UK centres between 25 May 2006 and 1 March 2020. Radiographs were assessed for Unified Classification System (UCS) grade and AO/OTA type. Statistical comparisons investigated relationships by age, gender, and stem fixation philosophy (polished taper-slip (PTS) vs composite beam (CB)). The effect of multiple variables was estimated using multinomial logistic regression to estimate odds ratios (ORs) with 95% confidence intervals (CIs). Surgical treatment (revision vs fixation) was compared by UCS grade and AO/OTA type. Results. A total of 584 cases were included. Median age was 79.1 years (interquartile range 72.0 to 86.0), 312 (53.6%) patients were female, and 495 (85.1%) stems were PTS. The commonest UCS grade was type B1 (278, 47.6%). The most common AO/OTA type was spiral (352, 60.3%). Metaphyseal split fractures occurred only with PTS stems with an incidence of 10.1%. Male sex was associated with a five-fold reduction in odds of a type C fracture (OR 0.22 (95% CI 0.12 to 0.41); p < 0.001) compared to a type B fracture. CB stems were associated with significantly increased odds of transverse fracture (OR 9.51 (95% CI 3.72 to 24.34); p < 0.001) and wedge fracture (OR 3.72 (95% CI 1.16 to 11.95); p = 0.027) compared to PTS stems. Both UCS grade and AO/OTA type differed significantly (p < 0.001 and p = 0.001, respectively) between the revision and fixation groups but a similar proportion of B1 fractures underwent revision compared to fixation (45.3% vs 50.6%). Conclusion. The commonest fracture types are B1 and spiral fractures. PTS stems are exclusively associated with metaphyseal split fractures, but their incidence is low. Males have lower odds of UCS grade C fractures compared to females. CB stems have higher odds of bending type fractures (transverse and wedge) compared to PTS stems. There is considerable variation in practice when treating B1 fractures around cemented stems. Cite this article: Bone Jt Open 2021;2(7):466–475

With an aging population and increase in total knee arthroplasty, periprosthetic distal femur fractures (PDFFs) have increased. The differences between these fractures and native distal femur fractures (NDFF) have not been comprehensively investigated. The purpose of this study was to compare the demographic, fracture, and treatment details of PDFFs compared to NDFFs. A retrospective study of patients ≥ 18 years old who underwent surgical treatment for either a NDFF or a PDFF from 2010 to 2020 at a level 1 trauma center was performed. Demographics, AO/OTA fracture classification, quality of reduction, fixation constructs, and unplanned revision reoperation were compared between PDFF patients and NDFF patients using t-test and Fisher's exact test. 209 patients were identified with 70 patients having a PDFF and 139 patients having a NDFF. Of note, 48% of NDFF had a concomitant fracture of the ipsilateral knee (14%) or tibial plateau (15%). The most common AO/OTA classification for PDFFs was 33A3.3 (71%). NDFFs had two main AO/OTA classifications of 33C2.2 (28%) or 33A3.2. (25%). When controlling for patient age, bone quality, fracture classification, and fixation, the PDFF group had increased revision reoperation rate compared to NDFF (P < 0.05). PDFFs tend to occur in elderly patients with low bone quality, have complete metaphyseal comminution, and be isolated; whereas, NDFF tend to occur in younger patients, have less metaphyseal comminution, and be associated with other fractures. When controlling for variables, PDFF are at increased risk of unplanned revision reoperation. Surgeons should be aware of these increased risks in PDFFs and future research should focus on these unique fracture characteristics to improve outcomes

Treatment of both simple and complex patella fractures is a challenging clinical problem. The aim of this study was to investigate the biomechanical performance of recently developed lateral rim variable angle locking plates versus tension band wiring used for fixation of simple and complex patella fractures. Twelve pairs of human anatomical knees were used to simulate either two-part transverse simple AO/OTA 34C1 or five-part complex AO/OTA 34C3 patella fractures by means of osteotomies, with each fracture model created in six pairs. The complex fracture pattern was characterized by a medial and a lateral proximal fragment, together with an inferomedial, an inferolateral, and an inferior fragment mimicking comminution around the distal patellar pole. The specimens with simple fractures were pairwise assigned for fixation with either tension band wiring through two parallel cannulated screws, or a lateral rim variable angle locking plate. The knees with complex fractures were pairwise treated with either tension band wiring through two parallel cannulated screws plus circumferential cerclage wiring, or a lateral rim variable angle locking plate. Each specimen was tested over 5000 cycles by pulling on the quadriceps tendon, simulating active knee extension and passive knee flexion within the range of 90° flexion to full knee extension. Interfragmentary movements were captured via motion tracking. For both fracture types, the longitudinal and shear articular displacements measured between the proximal and distal fragments at the central patella aspect between 1000 and 5000 cycles, together with the relative rotations of these fragments around the mediolateral axis were all significantly smaller following the lateral rim variable angle locked plating compared with tension band wiring, p<0.01. Lateral rim locked plating of both simple and complex patella fractures provides superior construct stability versus tension band wiring under dynamic loading

Treatment of simple and complex patella fractures represents a challenging clinical problem. Controversy exists regarding the most appropriate fixation method. Tension band wiring, aiming to convert the pulling forces on the anterior aspect of the patella into compression forces across the fracture site, is the standard of care, however, it is associated with high complication rates. Recently, anterior variable-angle locking plates have been developed for treatment of simple and comminuted patella fractures. The aim of this study was to investigate the biomechanical performance of the novel anterior variable-angle locking plates versus tension band wiring used for fixation of simple and complex patella fractures. Sixteen pairs of human cadaveric knees were used to simulate either two-part transverse simple AO/OTA 34-C1 or five-part complex AO/OTA 34-C3 patella fractures by means of osteotomies, with each fracture model created in eight pairs. The complex fracture pattern was characterized with a medial and a lateral proximal fragment, together with an inferomedial, an inferolateral and an inferior fragment mimicking comminution around the distal patellar pole. The specimens with simple fractures were pairwise assigned for fixation with either tension band wiring through two parallel cannulated screws, or an anterior variable-angle locking core plate. The knees with complex fractures were pairwise treated with either tension band wiring through two parallel cannulated screws plus circumferential cerclage wiring, or an anterior variable-angle locking three-hole plate. Each specimen was tested over 5000 cycles by pulling on the quadriceps tendon, simulating active knee extension and passive knee flexion within the range from 90° flexion to full knee extension. Interfragmentary movements were captured by motion tracking. For both fracture types, the articular displacements, measured between the proximal and distal fragments at the central aspect of the patella between 1000 and 5000 cycles, together with the relative rotations of these fragments around the mediolateral axis were all significantly smaller following the anterior variable-angle locked plating compared with the tension band wiring, p < 0.01. From a biomechanical perspective, anterior locked plating of both simple and complex patella fractures provides superior construct stability versus tension band wiring

Aims. The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients. Methods. In this multicentre study, 120 patients aged ≥ 60 years with an acute unstable AO/OTA type 44-B fracture of the ankle were randomized to fixation with either a nail or a plate and followed for 24 months after surgery. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. Secondary outcome measures were the Manchester-Oxford Foot Questionnaire, the Olerud and Molander Ankle score, the EuroQol five-dimension questionnaire, a visual analogue score for pain, complications, the quality of reduction of the fracture, nonunion, and the development of osteoarthritis. Results. At 24 months, the median AOFAS score was equivalent in the two groups (nail 90 (interquartile range (IQR) 82 to 100), plate 95 (IQR 87 to 100), p = 0.478). There were statistically more complications and secondary operations after nail than plate fixation (p = 0.024 and p = 0.028, respectively). There were no other significant differences in the outcomes between the two groups. Conclusion. The functional outcome after nail and plate fixation was equivalent; however, the complication rate and number of secondary operations was significantly higher after nail fixation. These results suggest that plate fixation should usually be the treatment of choice for unstable ankle fractures in the elderly. Cite this article: Bone Joint J 2023;105-B(1):72–81

Aims. To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years. Methods. A total of 100 patients were randomized in this non-inferiority trial, comparing cast immobilization with operation with a volar locking plate. Patients with displaced AO/OTA A and C fractures were eligible if one of the following were found after initial closed reduction: 1) dorsal angulation > 10°; 2) ulnar variance > 3 mm; or 3) intra-articular step-off > 2 mm. Primary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) after 12 months. Secondary outcome measures were the Patient-Rated Wrist and Hand Evaluation (PRWHE), EuroQol-5 dimensions 5-level questionnaire (EQ-5D-5L), range of motion (ROM), grip strength, “satisfaction with wrist function” (score 0 to 10), and complications. Results. In all, 89 women and 11 men were included. Mean age was 74 years (65 to 91). Nonoperative treatment was non-inferior to operation with a five-point difference in median QuickDASH after 12 months (p = 0.206). After three and six months QuickDASH favoured the operative group (p = 0.010 and 0.030). Median values for PRWHE were 19 (interquartile range (IRQ) 10 to 32) in the operative group versus ten (IQR 1 to 31) in the nonoperative group at three months (p = 0.064), nine (IQR 2 to 20) versus five (IQR 0 to 13) (p = 0.020) at six months, and two (IQR 0 to 12) versus zero (IQR 0 to 8) (p = 0.019) after 12 months. Range of motion was similar between the groups. The EQ-5D-5L index score was better (mean difference 0.07) in the operative group at three and 12 months (p = 0.008 and 0.020). The complication rate was similar (p = 0.220). The operated patients were more satisfied with wrist function (median 8 (IQR 6 to 9) vs 6 (IQR 5 to 7) at three months, p = 0.002; 9 (IQR 7 to 9) vs 8 (IQR 6 to 8) at six months, p = 0.002; and 10 (IQR 8 to 10) vs 8 (IQR 7 to 9) at 12 months, p < 0.001). Conclusion. Nonoperative treatment was non-inferior to operative treatment based on QuickDASH after one year. Patients in the operative group had a faster recovery and were more satisfied with wrist function. Results from previous trials comparing operative and nonoperative treatment for displaced distal radius fractures in the elderly vary between favouring the operative group and showing similar results between the treatments. This randomized trial suggests that most elderly patients may be treated nonoperatively. Cite this article: Bone Joint J 2021;103-B(2):247–255

To conduct a meta-analysis for intertrochanteric hip fractures comparing in terms of efficacy and safety short versus long intralomedullary nails. A pubmed search of the last 10 years for intertrochanteric fracture 31A1-31A3 according to the AO/OTA classification was performed. Baseline characteristics of each article were obtained, complication measures were analyzed: Peri-implant fracture, reoperations, deep/superficial infection, and mortality. Clinical variables consisted of blood loss (mL), length of stay (days), time of surgery (min) and nº of transfusions. Functional outcomes were also recorded. A meta-analysis was performed with Review Manager 5.4. Twelve studies were included, nine were retrospective. The reoperations rate was lower in the short nail group and the peri-implant fracture rate was lower in the long nail group (OR 0.58, 95% CI 0.38 to 0.88) (OR 1.88, 95% CI 1.04 to 3.43). Surgery time and blood loss was significantly higher in the long nail group (MD −12.44, 95% CI −14.60 to −10.28) (MD −19.36, 95% CI −27.24 to −11.48). There were no differences in functional outcomes. The short intramedullary nail has a higher risk of peri-implant fracture; however, the reoperation rate is lower compared to the long nail. Blood loss and surgery time was higher in the long nail group

The lateral wall thickness (LWT) in trochanteric femoral fractures is a known predictive factor for postoperative fracture stability. Currently, the AO/OTA classification uses a patient non-specific measure to assess the absolute LWT (aLWT) and distinguish stable A1.3 from unstable A2.1 fractures based on a threshold of 20.5 mm. This approach potentially results in interpatient deviations due to different bone morphologies and consequently variations in fracture stability. Therefore, the aim of this study was to explore whether a patient-specific measure for assessment of the relative LWT (rLWT) results in a more precise threshold for prediction of unstable fractures. Part 1 of the study evaluated 146 pelvic radiographs to assess left-right symmetry with regard to caput-collum-angle (CCD) and total trochanteric thickness (TTT), and used the results to establish the rLWT measurement technique. Part 2 reevaluated 202 patients from a previous study cohort to analyze their rLWT versus aLWT for optimization purposes. Findings in Part 1 demonstrated a bilateral symmetry of the femur regarding both CCD and TTT (p ≥ 0.827) allowing to mirror bone's morphology and geometry from the contralateral intact to the fractured femur. Outcomes in Part 2 resulted in an increased accuracy for the new determined rLWT threshold (50.5%) versus the standard 20.5 mm aLWT threshold, with sensitivity of 83.7% versus 82.7% and specificity 81.3% versus 77.8%, respectively. The novel patient-specific rLWT measure can be based on the contralateral femur anatomy and is a more accurate predictor of a secondary lateral wall fracture in comparison to the conventional aLWT. This study established the threshold of 50.5% rLWT as a reference value for prediction of fracture stability and selection of an appropriate implant for fixation of trochanteric femoral fractures

Lag screw cut-out is a serious complication of dynamic hip screw fixation in trochanteric hip fractures. Lag screw position is recognised as a crucial factor influencing the occurrence of lag screw cut-out. We propose a modification of the Tip Apex Distance (TAD) and hypothesize that it could enhance the reliability of predicting lag screw cut-out in these injuries. A retrospective study of hip fracture cases was conducted from January 2018 to July 2022. A total of 109 patients were eligible for the final analysis. The modified TAD was measured in millimetres, based on the sum of the traditional TAD in the lateral view and the net value of two distances in the anteroposterior (AP) view. The first distance is from the lag screw tip to the opposite point on the femoral head along the lag screw axis, while the second distance is from that point to the femoral head apex. The first distance is a positive value, whereas the second distance is positive if the lag screw is superior and negative if it is inferior. Receiver operating characteristic (ROC) curve analysis was used to assess the reliability of various parameters for evaluating the lag screw position within the femoral head. Factors such as reduction quality, fracture pattern according to the AO/OTA classification, TAD, Calcar-Referenced TAD, Axis Blade Angle, Parker’s ratio in the AP view, Cleveland Zone 1, and modified TAD were statistically associated with lag screw cut-out. Among the tested parameters, the novel parameter exhibited 90.1% sensitivity and 90.9% specificity for predicting lag screw cut-out at a cut-off value of 25 mm, with a p-value < 0.001. The modified TAD demonstrated the highest reliability in predicting lag screw cut-out. A value of 25 mm may potentially reduce the risk of lag screw cut-out in trochanteric hip fractures

Introduction. A subset of patients in cast awaiting fixation of ankle fractures require conversion to delayed external fixation (dEF). We aimed to evaluate the effect of delayed versus planned external fixation (pEF), then identify objective characteristics contributing to need for conversion. Method. We extracted data from our booking system to identify all ankle external fixation procedures between 2010 to 2022. Exclusions included open fractures, the skeletally immature, and pilon or talus fractures. Fractures were classified using the AO/OTA classification, then a matched cohort was identified based on fracture classification. We compared the planned, delayed and matched cohorts for demographics, posterior malleolar fragment (PMF) ratio, and degree of displacement at presentation. Results. We identified 25 pEF, 42 dEF, and 67 matched patients. Ankles with dEF had a 3.8 day longer time to ORIF from presentation than those who had pEF, and had an infection rate of 9.5%, compared to 4% in the pEF group. Two patients in the dEF group required further operative intervention. There were no infections or reoperations required in the pEF or matched groups. The dEF group were more likely to have ≥2 reductions (OR 4.13), a PMF ratio of >0.23 (OR 5.07), and have increased displacement at time of injury on lateral (32% vs 19%) and AP (62% vs 36%) radiographs. Discussion. Our retrospective study highlights the longer time to operation and increased infection rates of patients who do not get timely external fixation. We propose a series of objective parameters that predict failure of cast treatment and guide the surgeon to consider planned external fixation in some ankle

Introduction: The use of intramedullary nailing (IMHS) has increased at the expense of the dynamic hip screw (DHS), although the outcome is not different in the studies of pertrochanteric fractures (PTF), known as AO/OTA type 31A1-2 fractures with a preoperative intact lateral femoral wall. We therefore investigated the two implants in the subgroup of PTF with a fractured greater trochanter. Materials and Methods: Six hundred thirty-five consecutive patients with PTF fixated by a short IMHS or by a DHS mounted on a four hole lateral plate were prospectively included between 2002 and 2008. The fractures were preoperatively classified according to AO/OTA classification system, including status of the greater and lesser trochanter. The integrity of the lateral femoral wall, fracture reduction and implant positioning were assessed postoperatively. Reoperations due to technical failures were recorded for one year. Results: Among the 311 patients sustaining a PTF with a fractured greater trochanter, 4% (6/158) operated with an IMHS were reoperated compared to 14% (22/153) with a DHS (p=0.001). Multivariate logistic regression analysis combining demographic and biomechanical parameters showed the IMHS to have a lower rate of reoperation (p=0.002). During the operative procedure, the lateral femoral wall was fractured in 6% (9/158) of patients, in which an IMHS was performed versus 28% (42/153) operated with a DHS (p< 0.001). Among the DHS, a fractured lateral femoral wall was confirmed to be a predictor of a reoperation (31% (13/42) of patients with a fractured lateral femoral wall versus 8% (9/111) with an intact lateral femoral wall, p< 0.001). As in other studies, the different reoperation rate would have been overseen in the main group of AO/ OTA type 31A1-2 PTF fractures (4% (6/164) IMHS versus 6% (30/471) DHS, p=0.196). Conclusion: The IMHS seems to have a lower reoperation rate than the DHS in the subgroup of PTF with a fractured greater trochanter. In contrast to the DHS, the IMHS presumably keeps the integrity of the lateral femoral wall. In future studies, PTF should be divided into subgroups