Journal of orthopaedic trauma
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The purpose of this study is to identify the optimum entry point for retrograde femoral nailing, defined as that point which will provide adequate fracture alignment while minimizing soft-tissue and articular cartilage injury. ⋯ Retrograde femoral nailing should be used cautiously in select patients, when conventional antegrade nailing cannot be used, due to the unavoidable injury to the knee articular surface associated with this technique. The optimum entry point of 1.2 cm anterior to the femoral posterior cruciate ligament origin and centered in the intercondylar sulcus provides the optimal balance of fracture reduction and knee joint sparing. It may be difficult to target this site with a percutaneous technique and may require direct visualization of the intercondylar sulcus for ideal nail placement.
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The goal of the current study was to analyze the prospective clinical outcome of patients who failed closed or open treatment of a displaced intra-articular calcaneal fracture. This cohort of patients required a secondary subtalar fusion by distraction bone-block arthrodesis. ⋯ These data suggest that the amount of initial injury involved with the calcaneal fracture is the primary prognostic determinant of long-term patient outcome. Böhler angle on presentation of <0 degrees was 10 times more likely to require a secondary subtalar fusion than a Böhler angle on presentation of >15 degrees. Sanders-type IV calcaneal fractures were 5.5 times more likely to be fused than a simple Sanders type II fracture. Worker's Compensation Board patients were three times more likely to be fused than non-Worker's Compensation Board patients. Nonoperative care was six times more likely to lead to a late fusion as compared to open reduction and internal fixation treatment. Late fusion provided relief from pain and improved function as evidenced by an improvement in visual analogue score postsurgery. This study demonstrates that there is a distinct patient group with a displaced intra-articular calcaneal fracture who are at high risk of subtalar fusion. These include male Worker's Compensation Board patients who participate in heavy labor work with a fracture pattern with Böhler angle less than 0 degrees. If their initial treatment was nonoperative, the likelihood of requiring late subtalar fusion was significantly increased. Initial open reductional open reduction and internal fixation of patients with displaced intra-articular calcaneal fracture minimized the likelihood that subtalar fusion would be required.
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To evaluate the outcome of an uncommon variant of the anterior-posterior compression pelvic injury, in which the posterior ring injury is a midline sagittal sacral fracture extending into the spinal canal. ⋯ Patients who sustain sagittally oriented midline fractures of the sacrum that extend into the spinal canal (Denis zone III) as part of displaced, vertically stable anterior-posterior compression pelvic injuries, have a low incidence of neurologic deficit attributable to sacral root or plexus injury. This is in contrast to the high rate of neurologic deficit (>50%) otherwise reported in zone III sacral fractures, particularly in those associated with a displaced transverse component. In the midline sagittal fracture variant, simultaneous lateral displacement of both bony and neural elements through the midline may protect the sacral roots and plexi from significant traction or shear injury by maintaining the spatial orientation between the sacral foramina and sciatic notch. Long-term sequelae were related to urogenital complaints rather than to musculoskeletal problems, as 4 of the 10 patients in this series had either sexual or urologic dysfunction.
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Randomized Controlled Trial Clinical Trial
Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures: a cadaveric and biomechanical evaluation under cyclic loads.
To conduct a biomechanical comparison of a new triangular osteosynthesis and the standard iliosacral screw osteosynthesis for unstable transforaminal sacral fractures in the immediate postoperative situation as well as in the early postoperative weight-bearing period. ⋯ Triangular osteosynthesis for unstable transforaminal sacral fractures provides significantly greater stability than iliosacral screw fixation under in vitro cyclic loading conditions. In vitro cyclic loading, as a limited simulation of early stages of patient mobilization in the postoperative period, allows for a time-dependent evaluation of any fracture fixation system.