Comparison of Functional Outcome Between Trans– 2nd Metacarpal Fixation and Trans-Trapezius Fixation with K-Wire for Bennett Fracture

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Vol 7 | Issue 2 | July-December 2021 | page: 01-03 | Vishal V. Navale, Manasee Gulati

DOI-10.13107/ti.2021.v07i02.015

Author: Vishal V. Navale [1], Manasee Gulati [2]

[1] Department of Orthopaedics, Mysore Medical College and Research Institute, Mysore, Karnataka, India.
[2]Department of Physical Therapy, Manipal Academy of Higher Education, Manipal Hospitals, Bengaluru, Karnataka, India.

Address of Correspondence
Dr. Vishal V. Navale, Department of Orthopaedics, Mysore Medical College and Research Institute, Mysore, Karnataka, India.
E-mail: nvvishal2010@gmail.com

Abstract

Introduction: An articular fracture of the base of the thumb metacarpal consisting of a single, variable-sized, volar-ulnar fracture fragment is termed Bennett fracture. In the studies conducted so far there has been paucity in the knowledge about the methods of k wire fixation for the Bennett fracture and hence the purpose of this study is to compare functional outcome between the trans – 2nd metacarpal fixation and trans – trapezius fixation with K wire for Bennett fracture.
Methods: Patients were 18 years and above with no previous injury on the 1st metacarpal . Final assessment was performed from six months to nine months after the treatment with the DASH Score, VAS scale for pain, Hand Grip strength by Dynamometer. Radiographic images were taken at 6 months post-op in two separate views to evaluate post-traumatic arthritis of the first CMC joint.
Results: Statistical analysis showed a correlation between Pain and DASH score to be 0.946 in TTZ group and 0.966 in T2MC group and hence signifies that patients in T2MC group had a better functional outcome with lower DASH score and lower pain score. Significant correlation was seen between Pain and Grip strength, with -0.587 in TTZ group and -0.482 in T2MC group. Higher pain score correlated with higher DASH score and lower Grip strength and hence we can conclude that T2MC had a better functional outcome post-surgery than TTZ technique of fixation. Post op radiographs showed that T2MC group of patients had a better outcome with less arthritic complications and less pain and better grip strength.
Conclusion: This study gives us the overview about the two fixation methods of Bennett fracture , and that when trans 2nd metacarpal fixation is done , there are less chances of arthritis of the CMC joint as well as better functional outcomes post operatively as compared to trans trapezial fixation and hence guides a surgeon to make a decision about the technique of fixation to be employed during fixing such fracture.
Keywords: Bennett fracture, Trans-trapezial, Trans- 2nd metacarpal, Functional outcome

References

1. Drelich M, Godlewski P. Metacarpal fractures. Orthop Traumatol Rehabil 2004;6:331–335. 2. Kahler DM. Fractures and dislocations of the base of the thumb.J South Orthop Assoc 1995;4:69 –76. 3. Gedda KO, Moberg E. Open reduction and osteosynthesis of the so-called Bennett fracture in the carpo-metacarpal joint of the thumb. Acta Orthop Scand 1952;22:249–57. 4. Yin Y, Wang Y, Wang Z, Qu W, Tian W, Chen S. Accuracy of fluoroscopic examination in the treatment of Bennett fracture. BMC Musculoskelet Disord. 2021 Jan 4;22(1):3. doi: 10.1186/s12891-020-03867-1. PMID: 33397336; PMCID: PMC7783999. 5. Fractures of the Metacarpals and Phalanges: Charles S. Day. Greens Operative Hand surgery –Elsevier, 7th edition 2016, pg 272. 6. Fischborn T, Beckenbauer D, Held M, Daigeler A, Medved F. Analysis of operative techniques of fractures of the first metacarpal base. Ann Plast Surg 2018;80:507–14. 7. Hand – surgical treatment: Thomas P Ruedi. AO principles of fracture management – AO Publishing , second edition 2007, pg 683. 8. Kamphuis SJM, Greeven APA, Kleinveld S, Gosens T, Van Lieshout EMM, Verhofstad MHJ. Bennett fracture: Comparative study between open and closed surgical techniques. Hand Surg Rehabil. 2019 Apr;38(2):97-101. 9. Crosby CA, Wehbe MA, Mawr B. Hand strength: normative values. J Hand Surg Am 1994;19:665–70. 10. van Niekerk JL, Ouwens R. Fractures of the base of the first metacarpal bone: results of surgical treatment. Injury 1989;20:359–62. 11. Kamphuis SJM, Greeven APA, Kleinveld S, Gosens T, Van Lieshout EMM, Verhofstad MHJ. Bennett fracture: Comparative study between open and closed surgical techniques. Hand Surg Rehabil. 2019 Apr;38(2):97-101. doi: 10.1016/j.hansur.2018.11.003. Epub 2019 Jan 9. PMID: 30639054. 12. Greeven APA, Van Groningen J, Schep NWL, Van Lieshout EMM, Verhofstad MHJ. Open reduction and internal fixation versus closed reduction and percutaneous fixation in the treatment of Bennett fractures: A systematic review. Injury. 2019 Aug;50(8):1470-1477. doi: 10.1016/j.injury.2019.06.027. Epub 2019 Jun 28. PMID: 31288938.

How to Cite this article: Navale VV, Gulati M | Comparison of Functional Outcome Between Trans– 2nd Metacarpal Fixation and Trans-Trapezius Fixation with K-Wire for Bennett Fracture | July-December 2021; 7(2): 01-03.

 

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Volar Radiocarpal Subluxation an Unusual Complication Following Distal Radius Fracture Fixation with Locking Plate- A Case Report

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Vol 7 | Issue 2 | July-December 2021 | page: 09-11 | Chirag Thonse, Darshan Kumar A Jain, Akshay S Dudhanale, Anant Chaugule,
Madihah Faisal

DOI-10.13107/ti.2021.v07i02.017

Authors: Chirag Thonse [1], Darshan Kumar A Jain [2], Akshay S Dudhanale [1], Anant Chaugule [1],
Madihah Faisal [1, 2]

[1] Department of Orthopedics, Vikram Hospital, Millers Road, Bangalore, Karnataka, India.
[2] Department of Orthopedics, M.S. Ramaiah Medical College, MSRIT Post, Bangalore, Karnataka, India.
Address of Correspondence
Dr Akshay S. Dudhanale,
Fellow in Arthroscopy and Arthroplasty, Vikram Hospital Bangalore, Karnataka, India.
E-mail: akshay3664@gmail.com

Abstract

Introduction: Distal radius fractures are commonly treated by fixation using a volar locking plate. In some fracture patterns, this mode of fixation is not adequate. This case report aims to describe one such case.

Case report: We report a case of a 28-year-old gentleman who presented with volar subluxation of the radiocarpal joint early in the postoperative period following fixation of the distal end radius volar locking plate.

Conclusion: Volar locked plates have become the most common fixation strategy for distal radius fractures. In certain fracture patterns where a volar locking plate would be inappropriate, an alternative fixation strategy should be considered such as rim plate.

Keywords: Volar locking plate, Volar rim plate, Radiocarpal dislocation

References

1. International Journal of Research in Medical SciencesChavhan AN et al. Int J Res Med Sci. 2017 Feb;5(2): 574-582.

2. Alter, Todd H. and Ilyas, Asif M., “Complications Associated with Volar Locking Plate Fixation of Distal Radial Fractures.” (2018). Rothman Institute Faculty Papers. Paper 109. https://jdc.jefferson.edu/rothman_institute/109.

3. Wilson J, Viner JJ, Johal KS, Woodruff MJ. Volar Locking Plate Fixations for Displaced Distal Radius Fractures: An Evaluation of Complications and Radiographic Outcomes. Hand (N Y). 2018 Jul;13(4):466-472. DOI: 10.1177/1558944717717505. Epub 2017 Jul 9. PMID: 28691543; PMCID: PMC6081777.

4. Rohit Garg, Chaitanya S. Mudgal, When a volar locking plate is not the right choice in fractures of the distal radius: Case-based technical considerations, Journal of Clinical Orthopaedics and Trauma, Volume 11, Issue 4, 2020, Pages 542-553, ISSN 09765662, https://doi.org/10.1016/j.jcot.2020.05.040.(https://www.sciencedi rect.com/science/article/pii/S0976566220302320).

5. Alter, Todd H. and Ilyas, Asif M., “Complications Associated with Volar Locking Plate Fixation of Distal Radial Fractures.” (2018). Rothman Institute Faculty Papers. Paper 109. https://jdc.jefferson.edu/rothman_institute/109.

6. Harikrishnan Balakrishna Pillai, Suraj Sankar, Surendra Singh Rawat, Samarth Arya, Pradeep Jadhav. The functional outcome volar Barton fracture treated by open reduction and internal fixation with T plate – a prospective study. International Journal of Contemporary Medical Research 2020;7(6): F7-F11.

7. Müller ME, Koch P, Nazarian S, Schatzker J. Principles of the Classification of Fractures. In: Müller ME, Koch P, Nazarian S, Schatzker J, editors. The Comprehensive Classification of Fractures of Long Bones. Berlin, Heidelberg: Springer; 1990. p. 4–7.

8. Jupiter, Jesse B. MD Complex Articular Fractures of the Distal Radius: Classification and Management, Journal of the American Academy of Orthopaedic Surgeons: May 1997 – Volume 5 – Issue 3 – p 119-129.

9. Ilyas, Asif M. MD; Mudgal, Chaitanya S. MD Radiocarpal Fracturedislocations, Journal of the American Academy of Orthopaedic Surgeons: November 2008 – Volume 16 – Issue 11 – p 647-655.

How to Cite this article: Thonse C, Jain DKA, Dudhanale AS, Chaugule A, Faisal M | Volar Radiocarpal Subluxation an Unusual Complication Following Distal Radius Fracture Fixation with Locking Plate- A Case Report | Trauma International | July-December 2021; 7(2): 09-11.

 

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Chronic Tibial Tunnel Infection Following ACL Reconstruction: A Case Report and Review of the Literature

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Vol 7 | Issue 1 | January-June 2021 | page: 19-21 | Bishnu Pokharel, Rosan Prasad Shah Kalawar, Ashish Kumar Goyal

Author: Bishnu Pokharel [1], Rosan Prasad Shah Kalawar [1], Ashish Kumar Goyal

[1] Department of Orthopaedics, BPKIHS, Dharan, Nepal. [2] Department of Orthopaedics and Joint Replacement Surgery, Indrparastha Apollo Hospitals, Sarita Vihar, New Delhi, India.
Address of Correspondence
Dr. Ashish Kumar Goyal
Senior Registrar; Department of Orthopaedics and Joint Replacement Surgery Indrparastha Apollo Hospitals, Sarita Vihar, New Delhi, India.
Email: drgoyal41@gmail.com

Abstract

Introduction: Rupture of the anterior cruciate ligament (ACL) is a common injury in active people and one of the most common knee injuries in sports. Foreign body granuloma with concomitant infection is a rare complication in ACL surgery. Very few cases have been reported on it. We present a young patient with a chronic discharging sinus at a surgical site on the tibia in a diabetic patient and its successful management.  

 

 

Case Report: A thirty-two-year-old male presented to us with a persistent discharging sinus at the surgical site following an Anterior Cruciate Ligament (ACL) reconstruction two years back. Since then, he developed wound infection at the incision site created for graft harvesting, which kept on discharging sero-purulent discharge even with several antibiotics and local dressing courses. There was no stiffness or instability in the knee. We did a follow-up arthroscopic evaluation of the joint and debridement of the wound. A portion of hamstring graft and non-absorbable suture with unhealthy granulation tissues were found subcutaneously during the surgery. A partially resorbed bioscrew with unhealthy granulation tissue was observed in the tibial tunnel. After thorough debridement of the site, the wound completely healed.
Conclusion: Surgical site infection and foreign body granuloma should be considered and treated accordingly if the patient presents with persistent discharging sinus at the surgical site in ACL reconstruction
Keywords: Anterior cruciate ligament reconstruction, ACL, Surgical site infection, Tibial tunnel.

References

1) Miyasaka KC, Daniel D, Stone M, and Hirshman P. The incidence of knee ligament injuries in the general population. Am J Knee Surg. 1991; 4: 3-8.
2) Weiss KS, Weatherall JM, Eick J, and Ross JR. (2017). Delayed Tibial Osteomyelitis after Anterior Cruciate Ligament Reconstruction with Hamstrings Autograft and Bioabsorbable Interference Screw: A Case Report and Review of the Literature. Case Reports in Orthopedics. 2017; 1-7. doi:10.1155/2017/6383526.
3) Barber FA. Complications of Biodegradable Materials. Sports Medicine and Arthroscopy Review. 2015; 23(3):149-155. doi:10.1097/jsa.0000000000000076.
4) Barber FA. Complications of biodegradable materials: anchors and interference screws. Sports Medicine and Arthroscopy Review. 2015;3(3):149–155.
5) Frank M, Schmucker U, David S, et al. Devastating femoral osteomyelitis after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthr. 2008;16: 71–74. https://doi.org/10.1007/s00167-007-0424-7.
6) McAllister DR, Parker RD, Cooper AE, Recht MP, and Abate J. Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction. Am J Sports Med. 1999;27 : 562- 570.
7) Van Tongel A, Stuyck J, Bellemans J, and Vandenneucker H. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: a retrospective analysis of incidence, management and outcome. Am J Sports Med. 2007; 35 : 1059 – 1063.
8) Numazaki H, Kobayashi H, Yoshida K, Hakozaki M, and Konno SI. Prolonged infection at the tibial bone tunnel after anterior cruciate ligament reconstruction. Fukushima J Med Sci. 2017; 63(2):121-125. doi:10.5387/fms.2017-02. 9) O’Neill BJ, Molloy AP, and McCarthy T. Osteomyelitis of the tibia following anterior cruciate ligament reconstruction. International Journal of Surgery Case Reports. 2013;4(2): 143-145. doi: https://doi.org/10.1016/j.ijscr.2012.10.020.
10) Chua CG and Zubair M. A Modified Technique To Treat Infected Tibial Tunnel Post ACL Reconstruction: A Case Report. Malaysian Orthopedic Journal. 2019;13supplA.

How to Cite this article: Pokharel B, Kalawar RPS, Goyal AK | Chronic Tibial Tunnel Infection Following ACL Reconstruction: A Case Report and Review of The Literature | Trauma International | January-June 2021; 7(1): 19-21.

 

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Acute Scaphoidectomy and Lunocapitate Fusion for the Surgical Treatment of Compound Trans Styloid, Trans-Scaphoid, Peri-Lunate Fracture- Dislocation with Extensor Tendon Injury

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Vol 7 | Issue 1 | January-June 2021 | page: 15-18 | Divyesh V. Bukalsaria, Sachin Kale, Prakash D. Samant, Arvind Vatkar, Sanjay Dhar, Prasad Chaudhari

Author: Divyesh V. Bukalsaria [1], Sachin Kale [1], Prakash D. Samant [1], Arvind Vatkar [1], Sanjay Dhar [1], Prasad Chaudhari [1]

[1] Department of Orthopaedic Surgery, D Y Patil Medical College and Research Centre, Navi Mumbai, Maharashtra, India.
Address of Correspondence
Dr. Divyesh Vinod Bukalsaria,
Resident Physician, Department of Orthopaedic Surgery, D Y Patil Medical College and Research Centre, Navi Mumbai, Maharashtra, India.
E-mail: divyeshbukalsaria7@gmail.com

Abstract

Compound fracture-dislocations of proximal carpal bones are very rare. We report a 54-year-old male, laborer, who sustained a compound Gustilo Anderson type III-A dorsal wound with trans styloid, trans-scaphoid, peri-lunate dislocation with an extensor tendon injury. The patient underwent primary scaphoidectomy with Lunocapitate fusion with extensor tendon repair. On follow-up after 3 months, the patient had partial recovery of range of motion around the wrist without any significant discomfort.  

Keywords: Compound fracture-dislocation, Primary proximal row carpectomy, Trans-styloid trans scaphoidperilunate dislocation

References

1. Ali, Nadeem, et al. “Compound Transstyloid, Transscaphoid, Perilunate Fracture Dislocation.” Journal of the Scientific Society, vol. 40, no. 2, 2013, p. 111., doi:10.4103/0974-5009.115485.
2. Herzberg, G., and D. Forissier. “Acute Dorsal Trans-Scaphoid Perilunate Fracture-Dislocations: Medium-Term Results.” Journal of Hand Surgery, vol. 27, no. 6, 2002, pp. 498–502., doi:10.1054/jhsb.2002.0774.
3. Calandruccio, James H., et al. “Capitolunate Arthrodesis with Scaphoid and Triquetrum Excision.” The Journal of Hand Surgery, vol. 25, no. 5, 2000, pp. 824–832., doi:10.1053/jhsu.2000.16364.
4. Oehmke, M. J., et al. “The Blood Supply of the Scaphoid Bone.” Journal of Hand Surgery (European Volume), vol. 34, no. 3, Dec. 2009, pp. 351–357., doi:10.1177/1753193408100117.
5. Mayfield, Jack K. “Patterns of Injury to Carpal Ligaments.” Clinical Orthopaedics and Related Research, & NA; no. 187, 1984, doi:10.1097/00003086-198407000-00006.
6. Herzberg G, Comtet JJ, Linscheid RL, et al. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am.1993;18:768–79.
7. Herzberg, G., and D. Forissier. “Acute Dorsal Trans-Scaphoid Perilunate Fracture-Dislocations: Medium-Term Results.” Journal of Hand Surgery, vol. 27, no. 6, 2002, pp. 498–502., doi:10.1054/jhsb.2002.0774.
8. Herzberg, G., et al. “Perilunate Dislocations and Fracture-Dislocations: A Multicenter Study.” The Journal of Hand Surgery, vol. 18, no. 5, 1993, pp. 768–779., doi:10.1016/0363-5023(93)90041-z.
9. E. Hagert, M. Garcia-Elias, S. Forsgren, B.O. LjungImmunohistochemical analysis of wrist ligament innervation in relation to their structural composition
10. J Hand Surg, 32 (2007), pp. 30-36
11. Moody, Lisa, and Andrew Y. Zhang. “Treatment of an Unusual Trans-Scaphoid Perilunate Avulsion Fracture Dislocation: A Case Report.” Hand, vol. 10, no. 2, Mar. 2014, pp. 328–332., doi:10.1007/s11552-014-9634-x.
12. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, et al.Perilunate dislocation and fracture-dislocation: a critical analysis of the volar-dorsal approach. J Hand Surg Am. 1997;22:49–56.
13. Yao, Yu-Cheng, et al. “Lunocapitate Fusion with Scaphoid Excision for the Treatment of Scaphoid Nonunion Advanced Collapse or Scapho-Lunate Advanced Collapse Wrist.” Journal of the Chinese Medical Association, vol. 80, no. 2, 2017, pp. 117–120., doi:10.1016/j.jcma.2016.10.001

How to Cite this article: Bukalsaria DV, Kale S, Samant PD, Vatkar A, Dhar S, Chaudhari P | Acute Scaphoidectomy and Lunocapitate Fusion for the Surgical Treatment of Compound Trans Styloid, Trans-Scaphoid, Peri-Lunate Fracture-Dislocation with Extensor Tendon Injury | Trauma International | January-June 2021; 7(1): 15-18.

 

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Multi-Fragment Patellar Non-Union in a Young Patient Due to Failed Fixation and its Management – A Rare Case Report

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Vol 7 | Issue 1 | January-June 2021 | page: 12-14 | Neetin P Mahajan, Prasanna Kumar GS, Pranay Kondewar, Kishor Jadhav

Author: Neetin P Mahajan [1], Prasanna Kumar GS [1], Pranay Kondewar [1], Kishor Jadhav [1]

[1] Department of Orthopaedics, Grant Government Medical College, Mumbai, Maharashtra, India.
Address of Correspondence
Dr. Prasanna Kumar GS,
Department of Orthopaedics, Grant Government Medical College, Mumbai, Maharashtra, India.
E-mail: prasannakumargs5@gmail.com

Abstract

Introduction: Multi-fragmentary patellar non-union is rare and it causes functional disability in patients. The purpose of studying this case is to present an unusual patella multi-fragmentary non-union and discuss its management.
Case presentation: We present a case of a 25-year-old male patient presented with pain and instability and decreased movements of the right knee since last 1 year. The patient had a history of trauma for which he was operated at the local hospital. X-ray and CT scan of the right knee was suggestive of the non-union of the right patella with three main fragments. We managed with open reduction and internal fixation using CC screw, cerclage and tension band wiring. At one-year follow up, the patient is having a clinical and radiological union of non-union with good functional outcome.
Conclusion: Combination of cannulated cancellous screw, cerclage and tension band wiring provides stable fixation in the multi-fragmentary patellar non-union, helps in early mobilisation which in turn helps in getting good functional outcome and prevents implant-related complications.
Keywords: Non-union; Multi-fragmentary patella; Internal fixation; Fixation failure. 

 

 

References

1. E. J. Eric, “Fractures do joelho,” in Fractures em adultos, R. CAJ, D. P. Green, and R. W. Bucholz, Eds., vol. 1991, pp. 1729–1744, Lippincott, Philadelphia, PA, USA, 3rd edition.
2. Klassen JF, Trousdale RT. Treatment of delayed and nonunion of the patella. J Orthop Trauma. 1997;11(3):188–194.
3. Lachiewicz PF. Treatment of a neglected displaced transverse patella fracture. J Knee Surg. 2008;21:58–61.
4. Satku K, Kumar VP. Surgical management of non-union of neglected fractures of the pa-tella. Injury. 1991;22:108–10.
5. Dhar SA, Mir MR. Use of the Illizarov method to reduce quadriceps lag in the manage-ment of neglected non union of a patellar fracture. J Orthop. 2007;4:12.
6. Nathan ST, Fisher BE, Roberts CS, Giannoudis PV. The management of nonunion and delayed of unionof patella fractures: A systematic review of the literature. Int Orthop. 2011;35:791–5.
7. R. K. Baruah, “Modified Ilizarov in difficult fracture of the patella. A case report,” Jour-nal of Orthopaedic Case Reports, vol. 6, no. 1, pp. 26–28, 2016.
8. C. Gwinner, S. Märdian, P. Schwabe, K. D. Schaser, B. D. Krapohl, and T. M. Jung, “Cur-rent concepts review: fractures of the patella,” GMS Interdisciplinary plastic and recon-structive surgery DGPW, vol. 5, pp. 1–15, 2016.
9. Sutton S, Jr, Thompson C, Lipke J, Kettelkamp D. The effect of patellectomy on knee function. J Bone Joint Surg Am. 1976;58:537–40.
10. Lennox IA, Cobb AG, Knowles J, Bentley G. Knee function after patellectomy a 12- to 48-year follow-up. J Bone Joint Surg Br. 1994;76:485–7.

How to Cite this article: Mahajan NP, Prasanna Kumar GS, Kondewar P, Jadhav K | Multi-Fragment Patellar Non-Union in a Young Patient Due to Failed Fixation and its Management- A Rare Case Report | Trauma International | January-June 2021; 7(1): 12-14.

 

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Prospective Evaluation of The Results of External Fixation of Unstable Fractures of Distal Radius- A Comparison Between Open and Close Fractures and an Analysis of Similar Studies

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Vol 7 | Issue 1 | January-June 2021 | page: 05-11 | Brijesh Sharma, Vipul Agrawal, Rajendra Kumar Shakunt, Chandra Prakash Pal, Mayur Gupta, Rohit Yadav

Author: Brijesh Sharma [1], Vipul Agrawal [1], Rajendra Kumar Shakunt [1], Chandra Prakash Pal [1], Mayur Gupta [1], Rohit Yadav [1]

[1] Department of Orthopaedics, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India.
Address of Correspondence
Dr. Mayur Gupta,
Department of Orthopaedics, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India.
E-mail: mayur29.mg@gmail.com

Abstract

Background: Unstable or severely comminuted and intra-articular fractures of distal radius represent traumatic high energy injuries. Prospective study to evaluate the results of external fixation of such fractures was conducted from January 2017 to January 2020 in the Department of Orthopaedics. The aim of this study is to identify the results of external fixation of unstable fractures of distal radius and find out the best treatment options for such fractures under different clinical conditions by comparing the results for open and close fractures and analysis of similar studies.


Materials and Methods: 50 cases of unstable distal radius fractures, including 25 patients with open fractures and 25 patients with close fractures, were treated by external fixation. The patients had mean age of 33 years with 3:2 male female ratio. The fracture was anatomically reduced and fixed with external fixator. The mean follow up was of 24 months.




Results: Final assessment was done at 6 months postoperative follow up using the Sarmiento’s modification of Lindstrom criteria for radiological outcome, showing excellent to good results in 60% cases among open fracture group and 80% cases among close fracture group , Mayo Wrist Score for functional outcome showing excellent to good results in 52% cases among open fracture group and 76% cases among close fracture group. Long term assessment done using Jakim’s scoring system (for clinicoradiological correlation) at 24 months follow-up for all 50 patients, showed excellent to good results in 88% patients. Analysis of similar studies shows external fixation to be the most rewarding treatment option for varied clinical presentations of unstable fractures of distal radius.
Conclusions: Outcome at 6 months is significantly better in close fracture group as compared to open fracture group showing that good soft tissue cover is necessary for functional fracture healing. The long-term outcome in majority of the patients (44 cases) was excellent to good showing reliability of biological ligamentotaxis under various clinical presentations as suggested by analysis of similar studies. This treatment of choice leads to clinically rewarding functional, anatomical and radiological outcomes in unstable distal radius fractures.
Keywords: External fixation, ligamentotaxis, Distal radius.

References

[1] Cooney WP,Linscheid RL,Dobyns JH.External Pin Fixation for Unstable Colles’ Fractures.J Bone Joint Surg. 1979;61-A:840-5.
[2] Chung KC, Watt AJ, Kotsis SV, Margaliot Z, Haase SC, Kim HM (2006) Treatment of unstable distal radial fractures with the volar locking plating system. J Bone Jt Surg Am 88:2687–94
[3] Egol K, Walsh M, Tejwani N, McLaurin T, Wynn C, Paksima N (2008) Bridging external fixation and supplementary Kirschner wire fixation versus volar locked plating for the unstable fractures of the distal radius: a randomised, prospective trial. J Bone Jt Surg 90-A:1214–21
[4] Gouk, C., Ng, S.-K., Knight, M., Bindra, R., & Thomas, M. (2019). Long term outcomes of open reduction internal fixation versus external fixation of distal radius fractures: A meta-analysis. Orthopedic Reviews, 11(3). https://doi.org/10.4081/or.2019.7809
[5] Williksen JH, Husby T, Hellund JC, Kvernmo HD, Rosales C, Frihagen F. External Fixation and Adjuvant Pins Versus Volar Locking Plate Fixation in Unstable Distal Radius Fractures: A Randomized, Controlled Study With a 5-Year Follow-Up. J Hand Surg Am. 2015;40(7):1333-40. doi:10.1016/j.jhsa.2015.03.008
[6] Zhang Li-hai , Wang Ya-nan, Mao Zhi , Zhang Li-cheng, Li Hong-da, Yan Huan , Liu Xiao-xie , Tang Pei-fu . Volar locking plate versus external fixation for the treatment of unstable distal radial fractures: a meta-analysis of randomized controlled trials. J Surg Res. 2015;193(1):324-33. doi:10.1016/j.jss.2014.06.018
[7] Kasapinova K, Kamiloski V. Open reduction and internal fixation versus external fixation and/or kirschner wires for distal radius fractures. A systematic review. Pril (Makedon Akad Nauk Umet Odd Med Nauki). 2014;35(1):225-36. Review. PubMed PMID: 24802315.
[8] Shukla R, Jain RK, Sharma NK, Kumar R. External fixation versus volar locking plate for displaced intra-articular distal radius fractures: a prospective randomized comparative study of the functional outcomes. J Orthop Traumatol 2014;15:265-70.
[9] Gradl G, Wendt M, Mittlmeier T, Kundt G, Jupiter JB. Non-bridging external fixation employing multiplanar K-wires versus volar locked plating for dorsally displaced fractures of the distal radius. Arch Orthop Trauma Surg. 2013;133(5):595-602. doi:10.1007/s00402-013-1698-5
[10] Xuetao Xie, Xiaoxing Xie, Hui Qin, Longxiang Shen & Changqing Zhang (2013) Comparison of internal and external fixation of distal radius fractures, Acta Orthopaedica, 84:3,286-91, DOI: 10.3109/17453674.2013.792029
[11] Esposito J, Schemitsch EH, Saccone M, Sternheim A, Kuzyk PR. External fixation versus open reduction with plate fixation for distal radius fractures: a meta-analysis of randomised controlled trials. Injury. 2013;44(4):409-16. doi:10.1016/j.injury.2012.12.003
[12] Karantana A, Downing ND, Forward DP, Hatton M, Taylor AM, Scammell BE, Moran CG, Davis TR. Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial. J Bone Joint Surg Am. 2013 Oct 2;95(19):1737-44. doi:10.2106/JBJS.L.00232. PubMed PMID: 24088965.
[13] Walenkamp MM, Bentohami A, Beerekamp MS, Peters RW, vander Heiden R, Goslings JC, Schep NW (2013) Functional outcome in patients with unstable distal radius fractures, volar locking plate versus external fixation: a meta-analysis. Strategies Trauma Limb Reconstruction 8(2):67–75
[14] Wei DH, Raizman NM, Bottino CJ, Jobin CM, Strauch RJ, Rosenwasser MP (2009) Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate. J Bone Jt Surg 91-A:1568–77
[15] H J Kreder, D P Hanel, J Agel, M McKee, E H Schemitsch, T E Trumble, D Stephen.Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised, controlled trial. J Bone Joint Surg Br 2005;87:829-36.
[16] Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am. 2005;30(6):1185-99. doi:10.1016/j.jhsa.2005.08.009
[17] Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database SystRev 2003:CD003209.
[18] Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002;84:1093–110.
[19] Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am. 2007;89(7):1424-31. doi:10.2106/JBJS.F.01147
[20] Navarro CM, Pettersson HJ, Enocson A. Complications after distal radius fracture surgery: results from a Swedish Nationwide Registry study. J Orthop Trauma. 2015;29(2):E36-42.

How to Cite this article: Sharma B, Agrawal V, Shakunt RK, Pal CP, Gupta M, Yadav R | Prospective Evaluation of The Results of External Fixation of Unstable Fractures of Distal Radius- A Comparison Between Open and Close Fractures and an Analysis of Similar Studies | Trauma International | January-June 2021; 7(1): 05-11.

 

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To Evaluate The Outcome of Proximal Femoral Nail A2 in Management of Inter-trochanteric Fractures of Femur in Elderly

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Vol 7 | Issue 1 | January-June 2021 | page: 01-04 | Karuna Shankar Dinkar, Rohit Yadav, Arjun Uppal, Chandra Prakash Pal, Mayur Gupta

Author: Karuna Shankar Dinkar [1], Rohit Yadav [1], Arjun Uppal [1], Chandra Prakash Pal [1], Mayur Gupta [1]

[1] Department of Orthopaedic Surgery, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India.

Address of Correspondence
Dr. Chandra Prakash Pal,
Professor and Head Dept. of orthopedics, S. N. Medical College, Agra, Uttar Pradesh, India.
E-mail: drcportho@gmail.com

Abstract

Introduction- The incidence of inter-trochanteric fracture in the elderly is rising because of increased age and with low bone mineral density. The presence of osteoporosis in inter-trochanteric fractures is important because the fixation of the proximal fragment depends entirely on the quality of the cancellous bone present. The surgical stabilization of inter-trochanteric fractures remains a persistent challenge. The purpose of this study is to study the effectiveness and drawbacks of one such newer intramedullary device, Proximal Femoral Nail Antirotation in the management of inter-trochanteric fractures.

Material and method- Patients who underwent PFNA for inter-trochanteric fractures at a tertiary care center Agra, who have given written and informed consent. Patients fitting into inclusion criteria would form the study group. Data collected by interviews, observation of clinical and radiological findings and assessment of function done using Harris hip score.

Results- The study comprised 24 patients, with a mean age of mean age 63 years who suffered fracture inter-trochanteric femur, due to either trivial fall (75%) or RTA (17%) and managed by cephalomedullary nailing using Proximal Femoral Nai Antirotation at our center. The majority of the patients had the quality of reduction; the Majority of patients took 12 to 22 weeks for union with mean union time of 14 weeks. Patients were asked to follow up routinely, with post-operative follow up ranging from a minimum of 11 months to 18 months. At the final follow up following results obtained according to Harris Hip Score, were 55% patients excellent, 30.50% patients good, 12% patients fair, 2.50% patients poor.

Conclusions- The inter-trochanteric fracture in elderly patients treated with cephalomedullary nailing using proximal femoral nail-anti-rotation, which has the biomechanical advantage of the helical blade providing bone compaction, increasing surface area and better anchorage in the femoral head, which showed favorable outcome by retarding rotation and varus collapse and prevents medialization by acting as a central pillar.

Keywords- Inter-trochanteric fractures; Proximal femoral nail A2; Harris Hip Score.

References

1. Kaufer H. Mechanics of the Treatment of Hip Injuries. Clin Orthop. 1980;146:53 -61.
2. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty – two intertrochanteric hip fractures. A retrospective and prospective study. J Bone Joint Surg. 1979;61A: 216 – 21.
3. Kaufer H, Mathews LS, Sonstegard D. Stable Fixation of Intertrochanteric Fractures. J Bone Joint Surg. 1974;56A:899 – 907.
4. Sommers MB, Roth C, Hall H, Kam BC, Ehmke LW, Krieg JC,et al. A laboratory model to evaluate cutout resistance ofimplants.
5. Sadic S et al. Proximal Femoral Nail Antirotation in Treatment of Intertrochanteric Hip Fractures:a Retrospective Study in 113 Patients Med Arh. 2015 Dec; 69(6): 353-356.
6. Jin-Song Pu & Lei Liu & Guang-Lin Wang & Yue Fang & Tian-Fu Yang Results of the proximal femoral nail anti-rotation (PFNA) in elderly Chinese patients International Orthopaedics (SICOT) (2009) 33:1441–1444 DOI 10.1007/s00264-009-0776-3.
7. Chaoliang Lv, MD;Yue Fang, MS; Guanglin Wang,MD; Tianfu Yang, BS; Hui Zhang, MD; Yueming Song,MD. The New Proximal Femoral Nail Antirotation Asia: Early Results. Orthopaedics:10.3928/1477447-20110317-26
8. Sahin S, Ertürer E, Oztürk I, Toker S, Seçkin F, Akman S. Radiographic and functional results of osteosynthesis using the proximal femoral nail antirotation (PFNA) in the treatment of unstable intertrochanteric femoral fractures. Acta Orthop Traumatol Turc. 2010;44(2):127-34. doi: 10.3944/AOTT.2010.2237.for pertrochanteric fracture fixation. J OrthopTrauma. 2004;18(6):361–8.5
9. Kumar GN et al. Treatment of Unstable Intertrochanteric Fractureswith Proximal Femoral Nail Antirotation II: Our Experience in Indian Patients the Open Orthopaedics Journal, 2015, 9, 456-459
10. Jacobs RR, McClain O, Armstrong H J. Internal fixation of intertrochanteric hip fractures: a clinical and biomechanical study. Clin Orthop. 1980; 146:62 –70.
11. Simpson AH, Vart y K, Dodd C A. Sliding hip screws: modes of failure. Injury. 1989;20:227 – 31.

How to Cite this article: Dinkar KS, Yadav R, Uppal A, Pal CP, Gupta M | To Evaluate The Outcome of Proximal Femoral Nail A2 in Management of Inter-trochanteric Fractures of Femur in Elderly | Trauma International | Jauary-June 2021; 7(1): 01-04.

 

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A Comparative Study of Distal Tibia Metaphyseal Fractures in a Series of 50 Patients: Intramedullary Nailing (IMN) Vs Minimally Invasive Plate Osteosynthesis (MIPO)

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Outcomes of Cephalomedullary Nailing in The Treatment of Extracapsular Proximal Femur Fractures and Factors Affecting it

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Vol 6 | Issue 2 | July-Dec 2020 | page:2-6 | Vivek Sodhai, Meghraj Holambe, Chetan Pradhan, Atul Patil, Chetan Puram, Parag Sancheti, Ashok Shyam

Author: Vivek Sodhai [1], Meghraj Holambe [2], Chetan Pradhan [1], Atul Patil [2], Chetan Puram [2], Parag Sancheti [2], Ashok Shyam [2,3].

[1] Department of Trauma, Sancheti Institute Of Orthopaedics and Rehabilitation, Pune, India.
[2] Department of Orthopaedics, Sancheti Institute Of Orthopaedics and Rehabilitation, Pune, India.
[3] Department of Research, Indian Orthopaedic Research Group, Thane, India.

Address of Correspondence

Dr. Vivek Sodhai,
Lecturer, Department of Trauma, Sancheti Institute Of Orthopaedics and Rehabilitation, Pune, India.
E-mail: vivek.sodhai89@gmail.com

Abstract

Indroduction: Cephalomedullary nailing (CMN) has become popular in treatment of extracapsular proximal femur fractures due to its mechanical advantages. This study aims to analyse the functional outcomes of the same and factors affecting it.
Material and Methods: 140 prospective cases of extracapsular proximal femur fractures were treated with CMN between October 2016 and October 2017 with a minimum follow-up period of 12 months. Patients were clinically assessed with range of motion, weight bearing status, Harris hip score (HHS) and Short form (SF)-36 score. Radiologically, fracture reduction, change in neck shaft angle (NSA) and neck length ratio in comparison to unaffected hip.
Results: 140 patients, 52 had excellent while 88 had good HHS. Patient in age group 20-40 had an average HHS of 87.79, 40-60 age group had an average HHS of 87.41, while patients in age group > 60 years had an average HHS of 87.63. Patients achieved average full weight bearing at 9.94 ± 2.76 weeks (p-value 0.578). Change in the neck shaft angle (NSA) was statistically significant in the immediate post-operative and at 1-year radiographs (p-value <0.001). Comparison of neck length ratio between affected and unaffected hip showed no statistical difference. There was no significant difference in function, range of motion and HHS in males (88.51 ± 2.72) compared with females (87.61 ± 2.98) (p-value 0.082). There was no significant association between occurrence of limp with change in NSA and neck length ratio (all p values >0.05). 6 complications occurred (1 peri-implant fracture, 2 surgical site infections and 3 cases of helical blade migration).
Conclusion: CMN gives excellent functional outcomes in all AO types A1, A2, A3 irrespective of age and sex with early mobilisation, full weight bearing and better functional range of movement. Limp occurred independant of change in NSA and neck length ratio.
Keywords: Extracapsular proximal femur fractures; Cephalomedullary nailing; Unstable intertrochanteric fractures; Reverse oblique fractures..

References

1. Parker MJ, Handoll HH. (2008) Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev Jul 16;(3):CD000093.
2. Gullberg B, Johnell O, Kanis JA. (1997) World-wide projections for hip fracture. Osteoporos Int. 7(5):407-13.
3. Kaufer H, Mathews LS, Sonstegard D, Arbor A. (1974) Stable Fixation of Intertrochanteric Fractures A BIOMECHANICAL EVALUATION. J Bone Joint Surg. 56(5):899-907.
4. Weise K, Schwab E. (2001) Stabilization in treatment of per- and subtrochanteric fractures of the femur. Chirug. 72(11):1277-82.
5. Merredy P, Kamath S, Ramakrishnan M, et al. (2009) The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures. Injury. Apr;40(4):428–32.
6. Sircar P, Godkar D, Mahgerefteh S, Chambers K, Niranjan S, Cucco R. (2007) Morbidity and mortality among patients with hip fractures surgically repaired within and after 48 hours. Am J Ther. Nov-Dec;14(6):508–13.
7. Garg B, Marimuthu K, Kumar V, Malhotra R, Kotwal PP. (2011) Outcome of short proximal femoral nail antirotation and dynamic hip screw for fixation of unstable trochanteric fractures. A randomised prospective comparative trial. Hip Int. Sep-Oct;21(5):531–6.
8. Shen L, Zhang Y, Shen Y, Cui Z. (2013) Antirotation proximal femoral nail versus dynamic hip screw for intertrochanteric fractures: a meta-analysis of randomized controlled studies. Orthop Traumatol Surg Res. Jun;99(4):377–383.
9. Zou J, Xu Y, Yang H. (2009) A comparison of proximal femoral nail antirotation and dynamic hip screw devices in trochanteric fractures. J Int Med Res. Jul-Aug;37(4):1057–1064.
10. Hwang JH, Garg AK, Oh JK, Oh CW, Lee SJ, Myung-Rae C et al. (2012) A biomechanical evaluation of proximal femoral nail antirotation with respect to helical blade position in femoral head: a cadaveric study. Indian J Orthop. Nov;46(6):627–32.
11. Vaquero J, Munoz J, Prat S, Ramirez C, Aguado HJ, Moreno E et al. (2012) Proximal Femoral Nail Antirotation versus Gamma3 nail for intramedullary nailing of unstable trochanteric fractures. A randomised comparative study. Injury. Dec;43 Suppl 2:S47–S54.
12. D’Arrigo C, Carcangiu A, Perugia D, Scapellato S, Alonzo R, Frontini S et al. (2012) Intertrochanteric fractures: comparison between two different locking nails. Int Orthop. Dec;36(12):2545–2551.
13. Simmermacher RK, Ljungqvist J, Bail H, Hockertz T, Vochteloo AJ, Ochs U et al. (2008) The new proximal femoral nail antirotation (PFNA) in daily practice: results of a multicentre clinical study. Injury Aug;39(8):932–9.
14. Gadegone WM, Salphale YS. (2007) Proximal femoral nail – an analysis of 100 cases of proximal femoral fractures with an average follow up of 1 year. Int Orthop. Jun;31(3):403-8.
15. Boldin C, Seibert FJ, Frankhauser F, Peicha G, Grechenig W, Szyszkowitz R. (2003) The proximal femoral nail (PFN) — a minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand. Feb;74(1):53-8.
16. Krigbaum H, Takemoto S, Kim HT, Kuo AC. (2016) Costs and Complications of Short Versus Long Cephalomedullary Nailing of OTA 31-A2 Proximal Femur Fractures in U.S. Veterans. J Orthop Trauma. Mar;30(3):125-9.
17. Jacob J, Desai A, Trompeter A. (2017) Decision Making in the Management of Extracapsular Fractures of the Proximal Femur – is the Dynamic Hip Screw the Prevailing Gold Standard? Open Orthop J. Oct 31;11:1213-1217.
18. https://www2.aofoundation.org/wps/portal/surgerypopup?bone=Femur&segment=Proximal&showPage=indication&print=no&soloState=fbox&teaserTitle=&contentUrl=srg/popup/additional_material/31/31_Classification.jsp
19. Rosenblum SF, Zuckerman JD, Kummer FJ, Tam BS. (1992) A biomechanical evaluation of the gamma nail. J Bone Joint Surg Br. May;74(3):352-7.
20. Leung KS, So WS, Shen WY, Hui PW. (1992) Gamma nails and dynamic hip screws for peritrochanteric fractures: A randomised prospective study in elderly patients. J Bone Joint Surg Br. May;74(3):345-51.
21. Radford PJ, Needoff M, Webb JK. (1993) A prospective randomised comparison of the dynamic hip screw and the gamma locking nail. J Bone Joint Surg Br. Sep;75(5):789-93.
22. Puram C, Pradhan C, Patil A, Sodhai V, Sancheti P, Shyam A. (2017) Outcomes of dynamic hip screw augmented with trochanteric wiring for treatment of unstable type A2 intertrochanteric femur fractures. Injury. Aug;48 Suppl 2:S72-S77.
23. Kuzyk PR, Bhandari M, McKee MD, Russell TA, Schemitsch EH. (2009) Intramedullary versus extramedullary fixation for subtrochanteric femur Fractures. J Orthop Trauma Jul;23(6):465-70.
24. Xianshang Zeng, Ke Zhan, Lili Zhang, Dan Zeng, Weiguang Yu, Xinchao Zhang et al. (2017) Conversion to total hip arthroplasty after failed proximal femoral nail antirotations or dynamic hip screw fixations for stable intertrochanteric femur fractures: a retrospective study with a minimum follow-up of 3 years. BMC Musculoskelet Disord. 18:38.
25. Kothiyal P, Vij K, Gupta P, Rawat P, Sharma N. (2017) Functional evaluation of proximal femoral fractures managed with cephalomedullary nailing by oxford hip score – A prospective study. International Journal of Orthopaedics Sciences 3(3):980-985.
26. Christian Carulli, Federico Piacentini, Tommaso Paoli, Roberto Civinini, Massimo Innocenti. (2017) A comparison of two fixation methods for femoral trochanteric fractures: a new generation intramedullary system vs sliding hip screw. Clin Cases Miner Bone Metab. Jan-Apr;14(1):40-47.
27. Galanopoulos IP, Mavrogenis AF, Mageloikonomos PD, Vottis CT, Mitsiokapa E, Koulouvaris P et al. (2018) Similar function and complications for patients with short versus long hip nailing for unstable pertrochanteric fractures. SICOT J. 4:23.
28. Kleweno C, Morgan J, Redshaw J, Harris M, Rodriguez E, Zurakowski D et al. (2014) Short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years. J Orthop Trauma. Jul;28(7):391-7.
29. Robinson CM, Houshian S, Khan LA. (2005) Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. J Bone Joint Surg Am. Oct;87(10):2217-26.
30. Murena L, Moretti A, Meo F, Saggioro E, Barbati G, Ratti C et al. (2018) Predictors of cut-out after cephalomedullary nail fixation of pertrochanteric fractures: a retrospective study of 813 patients. Arch Orthop Trauma Surg. Mar;138(3):351–9.
31. Nherera L, Trueman P, Horner A, Watson T, Johnstone AJ. (2018) Comparison of a twin interlocking derotation and compression screw cephalomedullary nail (InterTAN) with a single screw derotation cephalomedullary nail (proximal femoral nail antirotation): a systematic review and meta-analysis for intertrochanteric fractures. J Orthop Surg Res. Dec;13:46.
32. Keong-Hwan Kim, Kye Young Han, Keun Woo Kim, Jun Hee Lee, Myung Ki Chung. (2018) Local Postoperative Complications after Surgery for Intertrochanteric Fractures Using Cephalomedullary Nails. Hip Pelvis. Sep;30(3):168-174.
33. WL Loo, SYJ Loh, HC Lee. (2011) Review of Proximal Nail Antirotation (PFNA) and PFNA-2 –Our Local Experience. Malaysian Orthopaedic Journal Vol 5 No 2.
34. Ma KL, Wang X, Luan FJ, Xu HT, Fang Y, Min J et al. (2014) Proximal femoral nails antirotation, Gamma nails, and dynamic hip screws for fixation of intertrochanteric fractures of femur: A meta-analysis. Orthop Traumatol Surg Res 100(8):859–66.

How to Cite this article: Sodhai V, Holambe M, Pradhan C, Patil A, Puram C, Sancheti P, Shyam A | Outcomes of cephalomedullary nailing in the treatment of extracapsular proximal femur fractures and factors affecting it. | Trauma International | July-December 2020; 6(2): 02-06.

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