Purnaganapathi Sundaram Velmurugesan

Coronal plane fractures are increasingly identified in multifragmentary pertrochanteric (AO Foundation/Orthopaedic Trauma Association [AO/OTA] 31-A2) fractures, yet their clinical significance is under-researched. The aim of this study was to evaluate whether wire augmentation during Proximal Femur Nail Antirotation Asia (PFNA-II) fixation improves functional outcomes—regain of abductor strength and modified Harris Hip Score (mHHS)—compared with PFNA-II alone at 18-month follow-up. The secondary outcomes such as time to union, pain scores (Visual Analog Scale [VAS]), and complications were also assessed. In this single-center, randomized controlled trial, 142 patients of Asian race and Indian ethnicity aged older than 60 years with AO-OTA 31-A2 fractures were treated using PFNAII, with or without wire augmentation for coronal fragments. Preoperative computed tomography (CT) assessed coronal fragment size. Among them, 116 patients who completed 18-month follow-up were analyzed. Modified intention-to-treat analysis was performed. At 18 months, augmentation produced greater abductor strength (Δ 8.21%, 95% confidence interval, 4.4-12.83; p < 0.001) with no significant difference in mHHS (Δ 3.31 points, −1.3-7.9; p = 0.16). In fragments >50%, wire augmentation led to a clinically relevant 10% strength gain, exceeding the minimal clinically important difference (MCID) of 8.2%. However, VAS was similar between groups. Controls showed more varus collapse, likely due to a persisting posteromedial void when the fragment is not stabilized. Wire augmentation improved abductor strength recovery, especially when fragment size exceeded 50%, supporting its use in such cases. However, mHHS were similar between the groups. Level I Therapeutic. See Instructions for Authors for a complete description of levels of evidence.

Mechanical instability due to long metaphyseal comminution and medial bone gap after lateral locking plate results in varus collapse and implant failure. We believe that fixation in the form of Nail and plate combination provides better stability and prevents complications. We performed a retrospective analysis of 56 distal femur fractures with long metaphyseal comminution treated in our institution with nail and plate construct from 2017 to 2023. The mean age was 43.1 years and the mean follow up was 24 Months (4-36 months). Of these 56 patients, 16 were closed injuries underwent primary fixation, and 40 were open injuries requiring staged reconstruction. At the final follow up, patients were assessed for shortening, knee range of movements, Sander et al. functional score, radiological union and loss in alignment. The mean length of metaphyseal comminution was 10.15 cm(5-18 cm). Primary Iliac crest bone grafting was done in 25 patients. Of the 56 patients, 51 achieved primary union and the mean time to union was 6 months. Of the remaining, 3 patients united after secondary bone grafting and 2 patients had nonunion. The mean loss in aLDFA at the final follow up was 1.75° in 7 patients. Shortening of the limb was noted in 16 patients, and 4 patients had significant shortening of 2 cm. Three patients developed deep SSI, of which one patient required debridement and 2 patients required implant removal. Patients achieved an average of 0-85° flexion and 0-5° extension. Functionally, 8 patients had excellent, 25 had good, 15 had fair and 8 patients had poor score. The technique of combined intramedullary nail and plate fixation provides adequate stability and achieves good outcome in distal femur fractures with segmental metaphyseal comminution. Nail restores the anatomical alignment, and the plate provides rotational stability to the short distal fragment.

Case: Three patients with central-lateral depression (CLD) fractures of the tibial plateau with an intact lateral cortical rim were treated using a lateral tibial plateau intra-articular osteotomy (LPO). These fractures are particularly challenging because of poor visualization of the articular surface and reliance on indirect reduction techniques in standard approaches often leading to malreduction. Osteotomy provides direct access to the depression, allows easy meniscal retrieval, anatomical reduction, bone grafting, and stable fixation. All patients achieved union and good functional outcomes. Conclusion: LPO may be useful in deep, angulated, or reverse-slope CLD fractures where standard approaches limit visualization and direct reduction. Level of Evidence: V. Level of Clinical Care: Level I Tertiary trauma centre.

OBJECTIVES: To identify risk factors for nonunion in distal femur fractures (DFFs) treated with lateral locking plates. METHODS: Design: Retrospective cohort study. Setting: Single Level I Trauma Center. Patient Selection Criteria: Adult patients with OTA/AO 33A and 33C DFFs treated with lateral locking plates between 2014 and 2019 were included. Outcome Measures and Comparisons: Nonunion, defined as the need for a subsequent surgical procedure to promote bone healing, was assessed in relation to patient demographics, comorbidities, injury, and fixation characteristics. RESULTS: A total of 298 patients (75.5% male; mean age 43.1 ± 13.7 years) were included. Among these, 166 fractures were classified as Orthopaedic Trauma Association (OTA)/Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 33A and 132 fractures as type 33C. Open fractures were present in 47.7%, and 72.1% had comminuted fractures. Nonunion occurred at 19.1% (57/298). No significant differences in age, sex, body mass index, smoking, or diabetes were observed between union and nonunion groups. Multivariable analysis identified open fracture [odds ratio (OR) 3.25; 95% confidence interval (CI) 2.10–5.02; P < 0.001], comminution (OR 2.85; 95% CI 1.89–4.31; P < 0.001), and medial void >1 cm (OR 4.50; 95% CI 2.80–7.30; P < 0.001) as independent predictors. Fixation characteristics, including plate material, length, screw configuration, and alignment, were not associated with nonunion. A post hoc composite variable, the “Terrible Triad,” combining open fracture, comminution, and medial void >1 cm, was associated with a 36.7% nonunion rate compared with 5.9% without the triad ( P < 0.001) and remained an independent predictor (OR 6.5; 95% CI 3.3–12.9; P < 0.001). CONCLUSIONS: The DFF “Terrible Triad” (open fracture, comminution, and medial void >1 cm) was a strong independent predictor of nonunion after lateral locked plating. Lateral locked plating fixation characteristics were not significantly associated with nonunion. Early recognition and targeted management of triad features may improve healing outcomes. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. LEVEL OF CLINICAL CARE: Level I tertiary trauma center.

Summary: Masquelet's induced membrane technique has become a preferred method for treating distal femoral segmental bone loss in recent years because it is easier to perform, highly reproducible, and requires less monitoring compared with bone transport. It involves 2 surgical stages: placing a temporary cement spacer in the first stage, followed by filling the bone defect with bone grafts in the second stage. The ideal spacer should be large enough to fill the defect, extending 2–3 cm beyond the bone ends on either side to optimize the graft incorporation and reduce the risk of nonunion. In addition, the wide bone morphology of the distal femur requires a large volume of cement compared with diaphyseal regions to adequately fill the defect. Removal of large spacers can be challenging, especially with a plate in place, often needing significant force, which could damage the membrane and weaken the bone. Therefore, making deep axial cuts (cementotomy) in the cement spacer soon after filling the defect may facilitate easier removal without damaging the membrane and leaving any residual spacer, improving the chances of successful reconstruction. The current report presents the Masquelet technique combined with cementotomy and describes the advantages of it.

Purpose The dynamic hip screw with fibular strut graft (DHS-FG) is a treatment method for femoral neck fractures (FNF) with multiple cortex comminution. Femoral neck systems (FNS) improve stability and prevent excessive neck shortening in FNFs. However, no comparative studies exist to determine method superiority. This study assesses the effectiveness and complications of DHS-FG versus FNS in treating comminuted FNFs. Methods Retrospective analysis of 50 patients (age 18–50) admitted to our institution with comminuted FNFs from January 2015 to March 2021. Patients were divided into 2 groups: DHS-FG (21 patients) and FNS (29 patients). Comparison parameters included operative time, intraoperative blood loss, fracture healing time, and complications (nonunion, neck shortening, avascular necrosis). Patient-reported outcomes were measured using Harris Hip Score at final follow-up. Results We followed all 50 patients for 24–72 months (mean 30 ± 2.07 months). There were no significant differences between the groups in age, gender, fracture classification, postoperative neck shaft angle, and tip-apex distance. However, the union rate differed significantly between DHS-FG and FNS groups (p < 0.05). Significant differences were also observed in surgical time (100 ± 9 vs. 76 ± 23 min), blood loss (370 ± 31 vs. 231 ± 123 ml), and complications (3 [14.2%] vs. 10 [34.4%]) in DHS-FG and FNS groups, respectively. Conclusion In comminuted FNFs, DHS-FG demonstrated superior union rates and lower complication rates than FNS. DHS-FG may be an effective treatment option for this fracture type, requiring further research to explore potential benefits and limitations of FNS in this context. Level of Evidence III. Level of Clinical Care Level I Tertiary trauma centre.

Acute metaphyseal tibial stress fractures (AMTSF) in the setting of severe osteoarthritis (OA) were relatively rare. Total knee arthroplasty (TKA) with a long stem was considered the preferred treatment. However, achieving rotational stability solely with a long stem at the metaphyseal level remained questionable. We report four female patients (mean age 65.3 ± 11.8) with AMTSF and severe OA between 2021 and 2022. All presented with sudden pain, weight-bearing inability, swelling, and proximal leg tenderness. Radiographs confirmed complete metaphyseal stress fractures. Each had vitamin D deficiency, and two had secondary hypoparathyroidism. Fractures were stabilized with medial plating to ensure rotational stability and provide a secure foundation for TKA. Knee Society Score and Functional Score improved from 14.8 ± 6.8 and 23 ± 16.2 to 86 ± 8.7 and 85 ± 10.3 (p < 0.05). No complications occurred during follow-up. In AMTSF with severe OA, TKA combined with plate osteosynthesis reliably achieves fracture union and excellent functional outcome. Level of evidence: IV. Level of clinical care: Level I Tertiary trauma center.