[Reduction techniques in intramedullary nailing osteosynthesis]

[Fracture-related infections after intramedullary nailing : Diagnostics and treatment]

Intramedullary nailing is the treatment of choice for a large number of fractures requiring surgery. In cases of fracture-related infections (FRI) the treatment of nail infections requires special attention due to the closed situation of the osteosynthesis material in the intramedullary canal. This article gives an overview of the general principles and diagnostic criteria for FRI after nail fixation and discusses the treatment recommendations based on three case examples. In cases of acute implant infections, an implant-retaining procedure is principally possible for both periprosthetic joint infections and FRI; however, after intramedullary nailing the nail should also be exchanged in cases of acute nail infections as a sufficient debridement of the nail is impossible due to its intramedullary location. In chronic FRI after intramedullary nailing a one-stage or two-stage procedure can be followed. In cases of adequate soft tissue coverage, good fracture reduction and an expected bone healing without critical bony substance defects, a one-stage procedure with nail exchange should be preferred. If a chronic infection with soft tissue and bone defects develops after intramedullary nailing, a two-stage procedure analogous to the treatment of osteomyelitis should be considered. In this case a multidisciplinary team approach with specialists in plastic surgery, microbiology and infectious diseases is necessary. The use of local antibiotics and antimicrobial-coated implants is deemed to be advantageous.

Does auxiliary cerclage wiring provide intrinsic stability in cephalomedullary nailing of trochanteric and subtrochanteric fractures?

Purpose

The aim of this study was to assess functional and radiological results following cephalomedullary nailing with and without use of auxiliary cable cerclages in a large series of trochanteric and subtrochanteric femoral fractures.

Methods

In a retrospective study of prospectively collected data between January 2014 and March 2019, a total of 260 consecutive patients (155 women and 105 men) with the diagnosis of AO/OTA A1 to A3 fractures were included. The mean age of patients was 76.4 ± 15.6 years. According to the AO/OTA classification, 72 A1 fractures, 124 A2 fractures, and 64 A3 fractures were found. In 72 patients with auxiliary cerclage wiring three A1 fractures, 27 A2 fractures and 42 A3 fractures were assessed. In the patient group with auxiliary cerclages, fracture healing according to the Radiographic Union Score for Hip (RUSH) within one year after surgery was assessed in 68 out of 72 patients (healing rate 94%). The mean RUSH in the group with cerclages was 28.7 ± 2.2 points and was 28.5 ± 2.2 points in the group without cerclages (p = 0.72). In 91 patients available for a complete follow-up, mean functional outcome according to the Lower Extremity Functional Scale (LEFS) was 65.3 ± 17.2 points in the group with cerclages versus 58.4 ± 21 points in the group without cerclages (p = 0.04).

Conclusion

The additional use of cerclages provides intrinsic stability and enables axial alignment and medial cortical support during anatomical fracture reduction and cephalomedullary nail insertion. In the current study, this technique resulted in significantly better functional long-term outcomes than without cerclages. Therefore, it can be recommended as a useful supportive tool especially in comminuted trochanteric and subtrochanteric fractures. Trial registration number DRKS00020550, 01/30/2020, retrospectively registered.

[Current treatment strategies for lower leg fractures in adults]

Shaft fractures of the tibia and fibula mainly affect younger patients and are therefore of great socioeconomic importance. Due to the high proportion of high-energy direct trauma mechanisms and the thin soft tissue covering layer of the ventromedian tibia, open factures occur in up to 39%. A structured diagnostic and therapeutic approach is essential for successful treatment. Reamed intramedullary nailing is currently the gold standard surgical procedure. The suprapatellar approach, representing an interesting alternative to the popular infrapatellar approach, postoperative complications, such as anterior knee pain as well as the management of non-unions are discussed in this article. Furthermore, the indications and the application of minimally invasive plate osteosynthesis (MIPO) and external fixators are described. Every trauma surgeon should be familiar with the etiology and the surgical treatment of compartment syndrome. A firm knowledge of the classifications of open and closed soft tissue injury is mandatory.