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Background We elucidated the effect of open reduction and internal fixation with locking plate for acute isolated displaced greater tuberosity fractures of humerus in elder adults (aged >60 years). Methods From 2009 to 2015, data from 32 patients, aged between 60 and 88 years, who had acute unilaterally displaced greater tuberosity fractures of humerus were collected and evaluated retrospectively. All the fractures were managed with open reduction and internal fixation with locking plate. The follow-up period was 50.8 months on an average (range 22-80 months). Finally, 25 patients were available for final evaluation of radiographic and functional results. Results All the 32 fractures had union with the average union time of 14 weeks (range 10-18 weeks) and with no complications. The average of preoperative Visual Analogue Scale (VAS) was 6.2 (range 4-8), ASES was 30.4 (range 13-45), and Constant score was 30.4 (range 20-45). At the last follow-up, the mean VAS was 1.3 (range 0-2.5), the mean ASES score was 90.1 (range 72-100), and the mean Constant score was 90.3 (range 80-100). There were statistically significant differences between preoperative and final follow-up in VAS, ASES, and Constant score. Hundred percent of patients had good or excellent results by Constant score, with excellent results (86-100) in 17 (68%) patients and good result (71-85) in 8 (32%). Conclusion In conclusion, open reduction and internal fixation with locking plate is an effective treatment for acute displaced greater tuberosity fractures of humerus in elder adults.

Background Cut-out failure is one of the most common complications in the Gamma3 nail fixation system. The purpose of this retrospective study was to determine pre-operative or intra-operative risk factors for cut-out failure of lag screws in unstable, intertrochanteric fractures fixed with short Gamma3 nails. Methods One hundred and seventy-six patients over 60 years of age, with unstable intertrochanteric fractures (AO/OTA 31-A2, 31-A3) treated with short Gamma3 nails were included in this study. All patients completed a minimum of 1-year follow-up. Analysis of post-operative radiographs included assessment for cut-out failure of lag screw, appropriateness of the entry point, posterior lag screw axis, fracture gaps, posterior displacement of the proximal fragment, and tip-apex distance. Results Of the 176 patients in this study, 22 patients were identified with cut-out failure. Multivariate logistic regression analysis revealed that improper entry point in an antero-posterior projection (odds ratio 10.39, 95% confidence interval 1.74–78.4), posterior displacement distance of the proximal fragment in a lateral projection (odds ratio 1.35, 95% confidence interval 1.17–1.59), and female sex (odds ratio 17.14, 95% confidence interval 1.88–876.11) were correlated with cut-out failure. Conclusion This study emphasizes the importance of an optimal position of reduction in the lateral projection in reducing the risk of cut-out failure. In addition, sex difference in bone mineral density, proximal femur geometry, and the bone strength in elderly females may explain why female sex is a risk factor.

Background Infected nonunion of the femoral shaft is uncommon, and usually presents with challenging therapeutic and reconstructive problems. There are still controversies over treating infected nonunion of the femoral shaft. The purposes of this retrospective study were to review the treatment outcomes and describe a staged protocol for spontaneous wound healing. Methods Six patients with chronic femoral shaft infected-nonunion from October 2002 to September 2010 were included in this retrospective study. Serial plain films and triple films of lower legs were performed to evaluate the alignment of the treated femoral shaft and bony union following our staged protocol of Ilizarov distraction osteogenesis and intramedullary nailing. Results An average bone defect of 7 cm was noted after staged osteotomy. Mean follow-up was 87.5 (range, 38–133) months. Union was achieved in all six patients, with an average external fixation time of 6.8 (range, 5–11) months. There was no reinfection. One complication of a 4-cm leg discrepancy was noted, with an initial shortening of 15 cm. The mean knee ranges of motion (ROM) before staged protocols and at final follow-up were 64.2 ± 8.6 (range, 60–75)° and 53.3 ± 9.3 (range, 40–65)°, respectively. The ROM at the knee joint statistically decreased following staged protocols. Conclusion In the treatment of chronic femur osteomyelitis, the staged protocol of Ilizarov distraction osteogenesis followed by intramedullary nailing was safe and successful, and allowed for union, realignment, reorientation, and leg-length restoration. With regard to the soft tissue, this technique provides a unique type of reconstructive closure for infected wounds. It is suggested that the staged protocol is reliable in providing successful simultaneous reconstruction for bone and soft tissue defects without flap coverage.

Background Osteonecrosis of the femoral head (ONFH) is an important indication for total hip arthroplasty in Taiwan. We demonstrated the etiologies of ONFH and outcomes based on stratification of patients according to different etiologies. Methods We reviewed medical records and images from January 2000 to May 2010 in our database with the diagnosis of “osteonecrosis of the femoral head.” We categorized all patients into different etiologies, including corticosteroid, alcohol, and idiopathic. All patients received subsequent follow up for ipsilateral precollapse ONFH and contralateral disease-free femoral head status after initial diagnosis. Results Of the 1153 patients who had undergone 1674 hip surgeries including core decompression and total hip replacement, alcohol use was the most prevalent etiology in our population (45.2%). Patients with corticosteroid- and alcohol-associated ONFH were younger and more likely to have bilateral disease. Patients with alcohol- or steroid-associated ONFH were found to have a higher rate of contralateral disease and faster progression of precollapse ONFH than patients who had or had not undergone core decompression. Conclusion Alcohol use had the greatest impact on ONFH in our population. Nonidiopathic ONFH patients had the worst outcome. Understanding the nature of progression of ONFH and incidence of contralateral disease may provide great prognostic value to detect and perform early intervention.

Background Treatment options for nonunion of the femoral shaft fracture after intramedullary nail fixation are controversial. The methods of exchanging an existing nail with a larger-sized nail, dynamization, removal of the nail followed by plating, and bone grafting have all been reported. From those options, exchange nailing seems to be the most popular choice. In our study, we used plate augmentation and bone grafting with retention of the nail. The purpose of our study was to evaluate the effectiveness of this method in treating femoral shaft nonunion after open reduction and internal fixation with intramedullary nail fixation. Methods Between January 2003 and December 2009, 22 patients who had nonunion after open reduction and internal fixation with intramedullary nail for femoral shaft fracture were included in our study. There were 13 men and nine women participants, with a mean age of 34.3 years (range, 17–77 years). The mean period of nonunion after surgery was 20.0 months (range, 7–63 months). The patients were classified into three groups, atrophic, oligotrophic, and hypertrophic. We retained the nail and performed plate augmentation for all patients, with simultaneous autologous bone grafting as indicated. We followed up on all patients with plain film examination, and to assess functional recovery status to determine osseous union condition. Results All 22 of the patients achieved postoperative bony union uneventfully at a mean time of 22.1 weeks (range, 12–40 weeks). The mean operative time was 105 minutes (range, 60–150 minutes), and the mean blood loss was 340 ml (range, 150–700 ml). All of the patients could walk bearing full weight without pain within 3 months. There were no significant complications such as broken hardware, implant back-out, axial or rotational malalignment, or deep infections. Conclusion Plate augmentation with retention of the nail with autologous bone grafting may be an effective and reliable alternative in treating nonunion of the femoral shaft fracture after open reduction and internal fixation with intramedullary nail.

Background Infection is one of the most devastating complications after primary total knee arthroplasty (TKA). Antibiotics-impregnated cement has been used and proven effective in preventing deep infection. This study was to evaluate the long-term results of using cefuroxime-impregnated cement and systemic cefazolin for one week to assess their efficacy in preventing infection of primary TKA. Methods From 1999 to 2007, 2700 cases of primary TKA were performed with cemented fixation of all patellar, tibial, and femoral components. Cefuroxime-impregnated cement for fixation and systemic cefazolin for one week were selected in all cases. The average follow-up period was 89 months (range, 40–140). The effects of this selected regime in the periprosthetic infection were evaluated. Results A total of eight infections occurred after primary TKA, including five deep infections (0.19%) and three superficial infections (0.11%) in the 2700 knees. No loosening or osteolysis was noted. Conclusion Comparable with other measurements, cefuroxime-impregnated cement, accompany by systemic cefazolin for 1 week was shown to control postoperative deep infection to 0.19% (after primary TKA was performed in an operative setting without lamina flow and body exhaust suit).

Background: Open reduction and internal fixation with tension band wire is the standard treatment for displaced transverse patellar fractures. Recently, some minimally invasive techniques have been proposed as possible alternative methods. This retrospective study compared a newly reported percutaneous osteosynthesis with conventional open method for the treatment of displaced transverse patellar fractures. Methods: The minimally invasive technique was performed by percutaneous osteosynthesis with modified Carpenter’s (POMC) technique, using figure-eight wiring through two-paired cannulated screws under the control of arthroscopy and fluoroscopy. The conventional open surgery was performed with open modified anterior tension band (OMATB) technique. Totally 60 displaced transverse fractures were included in our study. Twenty were treated with percutaneous technique and 40 with open method. Outcome assessment included analysis of radiographic images, range of motion, Lysholm scores, complications, and reoperations. Results: Mean follow-up was 37.3 months. Comparison of POMC and OMATB groups showed statistically significant results as follows: shorter surgical time, 70.4 � 12.5 minutes for POMC group; greater degrees of flexion, 140.4 � 6.1 for POMC group; better total range of motion, 139.6 � 8.2 for POMC group; higher Lysholm scores, 93.6 � 3.1 for POMC group. Frequencies of total complications and reoperations were significantly lower in POMC group. Conclusion: POMC method was a reproducibly reliable method, offering better functional outcome, lower incidence of complications, and reoperations, as compared with standard OMATB group for transverse patellar fractures. Nevertheless, it is not recommended for severely comminuted fractures. Copyright 2011 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.

Fibrous dysplasia, a condition in which the skeleton fails to develop normally, is characterized by fibroblastic stroma and immature bone. Bowing of the long bones occurs frequently in the polyostotic form, and stress fractures often result. Shepherd's crook deformity is a characteristic feature of fibrous dysplasia. The goal of its treatment is to obtain normal walking ability and relieve pain due to pathologic fracture secondary to the deformity; however, correction of the deformity is a surgical challenge. We present 2 cases of shepherd's crook deformity treated with corrective osteotomy and a dynamic hip screw. Both cases showed good bone healing and no recurrent deformity. The gross deformities were corrected, and both patients were pain-free after operation.

Background This study was conducted to evaluate the results of treating hypertrophic nonunion of mid-shaft clavicle fracture with a limited contact dynamic compression plate (LC-DCP) without autologous cancellous bone graft. Methods From 1995 to 2008, 51 cases of hypertrophic nonunion of mid-shaft clavicle fracture were managed with open reduction and internal fixation by LC-DCP without bone graft involvement. Of these 51 cases, 30 had nonunion after failure of initial surgical treatment (Group 1), and 21 had nonunion after failure of conservative treatment (Group 2). Preoperative and postoperative case management were the same for both groups, with the average follow-up period being 20.4 months (range 18–36). Our study evaluated the radiographic results and functional outcomes of these cases according to the quick disability of arm, shoulder, and hand score. Results All 51 cases resulted in uneventful unions. There was no statistically significant difference between the two groups regarding patient demography, cause of injury, preoperative and postoperative functional scores, length of operation, union time, and duration of hospitalization (p > 0.05). Conclusion LC-DCP fixation is an effective method for treating hypertrophic nonunion of mid-shaft clavicle fracture. Local bone graft is sufficient to achieve necessary union, and autologous bone graft from other sites of the body appears unnecessary.