RESUMEN

Malunion, nonunion, congenital abnormalities, and osteometabolic diseases are the main causes of long bone deformities1. Although the exact incidence is unclear, it is estimated that about 10% of all fractures have some complication in terms of fracture-healing. In addition to the aesthetic impact, malunions generally substantially impair function and quality of life1. Every malunion is unique, and treatment is usually planned according to the degree of deformity and the postoperative expectations of the patient2. However, it is noteworthy that deformity correction usually requires a high degree of surgical expertise. Several techniques have been proposed over the years, and new techniques that utilize current technologies are available, such as computer-assisted single-cut osteotomy3. In 2009, Russell et al. proposed the clamshell technique for diaphyseal malunions4-6. This technique is our preferred treatment for diaphyseal malunions and acute fractures in the setting of a previous malunion or deformity. The following videos will thoroughly describe the steps to perform this useful and effective surgical technique for malunion correction. DESCRIPTION: The key principle of the "clamshell osteotomy" is to create a comminuted fracture at the malunion site and utilize an intramedullary rod as a template for deformity correction4,5. ALTERNATIVES: Multiple osteotomy types and fixation methods are currently available for diaphyseal malunion correction. Among the osteotomies, opening or closing wedge, uniplanar, multiplanar, oblique, and dome methods may be utilized. In addition, several fixation methods can be utilized, including plates and screws, intramedullary rods, and external fixators2,6. RATIONALE: The clamshell technique is a useful and effective treatment option for diaphyseal malunions of the lower extremity. The ability to utilize an intramedullary nail as a template for deformity correction makes the procedure simpler than previously described techniques, which require perfect preoperative planning to avoid over- and undercorrection. The versatility of this procedure justifies its incorporation into the therapeutic arsenal for treatment of complex diaphyseal malunions. EXPECTED OUTCOMES: To our knowledge, all previously reported cases utilizing the clamshell osteotomy have resulted in positive outcomes4-6. Russell et al. presented a case series of 10 patients with posttraumatic diaphyseal malunions (4 femoral and 6 tibial), in which all patients showed coronal and sagittal-plane correction to within 4°, limb-length inequality correction to within 2 cm, and complete correction of translation, rotation, and joint-line orientation angles4. In addition, all osteotomies healed uneventfully. The reported complications included broken interlocking screws in 1 case, need for dynamization in 1 case, and superficial wound dehiscence in 2 cases (1 of which required surgical debridement). Pires et al. presented 4 cases of clamshell osteotomies performed for the treatment of acute fractures in the setting of a previous malunion. All osteotomies healed by 15 months (mean time to healing [and standard deviation], 6.8 ± 4.4)6. One of these 4 cases was a Gustilo-Anderson grade-IIIB open fracture that required muscle flap coverage and a subsequent Hernigou procedure6. When discussing treatment options with patients, it is important to clarify that there is currently no clear best technique to treat complex malunions; however, the clamshell osteotomy is a simpler procedure compared with others that have previously been described and has the benefits of quick rehabilitation and good deformity correction without the drawbacks of an external fixator4-6. IMPORTANT TIPS: Preserve the blood supply in the opposite cortex.Close the fascia before reaming the medullary canal.Do not ream the osteotomy site.Be sure to perform a bicortical osteotomy.Create a stable construct.

RESUMEN

OBJECTIVE: Evaluate complication rates and functional outcomes of fibular neck osteotomy for posterolateral tibial plateau fractures. DESIGN: Retrospective case series. SETTING: University hospital. PATIENTS: From January 2013 to October 2014, 11 patients underwent transfibular approach for posterolateral fractures of the tibial plateau and were enrolled in the study. All patients who underwent transfibular approach were invited the return to the hospital for another clinical and imaging evaluation. INTERVENTION: Transfibular approach (fibular neck osteotomy) with open reduction and internal fixation for posterolateral fractures of the tibial plateau. MAIN OUTCOME MEASUREMENTS: Complications exclusively related to the transfibular approach: peroneal nerve palsy; knee instability; loss of reduction; nonunion and malunion of fibular osteotomy; and functional outcomes related to knee function. RESULTS: Two patients failed to follow-up and were excluded from the study. Of the 9 patients included in the study, no patients demonstrated evidence of a peroneal nerve palsy. One patient presented loss of fracture reduction and fixation of the fibular neck osteotomy, requiring revision screw fixation. There were no malunions of the fibular osteotomy. None of the patients demonstrated clinically detectable posterolateral instability of the knee following surgery. American Knee Society Score was good in 7 patients (77.8%), fair in 1 (11.1%), and poor in 1 (11.1%). American Knee Society Score/Function showed 80 points average (60-100, S.D:11). CONCLUSION: The transfibular approach for posterolateral fractures is safe and useful for visualizing posterolateral articular injury. The surgeon must gently protect the peroneal nerve during the entire procedure and fix the osteotomy with long screws to prevent loss of reduction. LEVEL OF EVIDENCE: Therapeutic level IV.

Asunto(s)

Peroné/cirugía , Fijación Interna de Fracturas , Osteotomía/métodos , Nervio Peroneo/diagnóstico por imagen , Fracturas de la Tibia/cirugía , Adulto , Tornillos Óseos , Brasil , Femenino , Fijación Interna de Fracturas/métodos , Curación de Fractura , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Estudios Retrospectivos , Fracturas de la Tibia/diagnóstico por imagen , Fracturas de la Tibia/fisiopatología , Resultado del Tratamiento , Adulto Joven

RESUMEN

As fraturas atípicas do fêmur são raras, mas sua crescente descrição na literatura e sua provável associação com os bifosfonatos trouxeram à tona uma série de aspectos ainda nebulosos no tocante ao uso contínuo dessas drogas. O protocolo mais sugerido atualmente, embora ainda não totalmente estabelecido, orienta a retirada da medicação após três a cinco anos de uso contínuo dos bifosfonatos, retornando cerca de três anos depois, quando houver necessidade

---

Atypical femur fractures are rare but a growing concern, as they are more common in patients who use long-term bisphosphonates. This brought to light a number of issues still unknown regarding the continued use of these drugs. Nowadays the most suggested protocol, although not yet fully esbablished, considers not more than three to five years of bisphosphonate treatment for osteoporotic patients, returning about three years later, when the need arises

Asunto(s)

Humanos , Masculino , Femenino , Difosfonatos/administración & dosificación , Difosfonatos/uso terapéutico , Fracturas del Fémur/etiología , Diáfisis , Difosfonatos/efectos adversos , Difosfonatos/farmacología , Fijación Intramedular de Fracturas , Fracturas de Cadera , Osteoporosis/fisiopatología , Osteoporosis/tratamiento farmacológico , Teriparatido/uso terapéutico

RESUMEN

BACKGROUND: Z-effect and reverse Z-effect are complications that arise from the surgical treatment of pertrochanteric fractures of the femur with proximal femoral nails (PFN) comprising two interlocking head screws. Such complications are induced by the migration of screws in opposite directions, which may lead to failure of the osteosynthesis. FINDINGS: The paper describes three cases of pertrochanteric fractures that were treated with PFN with two interlocking screws that evolved to either Z-effect or reverse Z-effect. Literature-based explanations for this phenomenon are provided together with recommendations of how to avoid such complications. CONCLUSIONS: Although intramedullary fixation is an established method of treatment of femoral intertrochanteric and subtrochanteric fractures, the evolution of the procedure may include complications associated with the migration of the interlocking head screws. The occurrence of Z-effect and reverse Z-effect has not been completely elucidated, but the main causes of such complications are probably fracture fixation in varus position, severe medial comminution, inappropriate entry point of the nail and poor bone quality.