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Slobogean GP, Bzovsky S, O'Hara NN, Marchand LS, Hannan ZD, Demyanovich HK, Connelly DW, Adachi JD, Thabane L, Sprague S, Sprague S, Adachi JD, Bhandari M, Thabane L, Holick MF, Bzovsky S, Simunovic N, Madden K, Scott T, Duong A, Heels‐Ansdell D, Hannan ZD, Connelly DW, Rudnicki J, Pollak AN, O'Toole RV, LeBrun C, Nascone JW, Sciadini MF, Degani Y, Pensy R, Manson T, Eglseder WA, Langhammer CG, Johnson AJ, O'Hara NN, Demyanovich H, Howe A, Marinos D, Mascarenhas D, Reahl G, Ordonio K, Isaac M, Udogwu U, Baker M, Mulliken A, Atchison J, Schloss MG, Zaidi SMR, McKegg PC, DeLeon GA, Ghulam QM, Camara M, Marchand LS. Effect of Vitamin D 3 Supplementation on Acute Fracture Healing: A Phase II Screening Randomized Double-Blind Controlled Trial. JBMR Plus 2022; 7:e10705. [PMID: 36699638 PMCID: PMC9850434 DOI: 10.1002/jbm4.10705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 11/11/2022] [Accepted: 11/16/2022] [Indexed: 11/20/2022] Open
Abstract
Nearly half of adult fracture patients are vitamin D deficient (serum 25-hydroxyvitamin D [25(OH)D] levels <20 ng/mL). Many surgeons advocate prescribing vitamin D supplements to improve fracture healing outcomes; however, data supporting the effectiveness of vitamin D3 supplements to improve acute fracture healing are lacking. We tested the effectiveness of vitamin D3 supplementation for improving tibia and femur fracture healing. We conducted a single-center, double-blinded phase II screening randomized controlled trial with a 12-month follow-up. Patients aged 18-50 years receiving an intramedullary nail for a tibia or femoral shaft fracture were randomized 1:1:1:1 to receive (i) 150,000 IU loading dose vitamin D3 at injury and 6 weeks (n = 27); (ii) 4000 IU vitamin D3 daily (n = 24); (iii) 600 IU vitamin D3 daily (n = 24); or (iv) placebo (n = 27). Primary outcomes were clinical fracture healing (Function IndeX for Trauma [FIX-IT]) and radiographic fracture healing (Radiographic Union Score for Tibial fractures [RUST]) at 3 months. One hundred two patients with a mean age of 29 years (standard deviation 8) were randomized. The majority were male (69%), and 56% were vitamin D3 deficient at baseline. Ninety-nine patients completed the 3-month follow-up. In our prespecified comparisons, no clinically important or statistically significant differences were detected in RUST or FIX-IT scores between groups when measured at 3 months and over 12 months. However, in a post hoc comparison, high doses of vitamin D3 were associated with improved clinical fracture healing relative to placebo at 3 months (mean difference [MD] 0.90, 80% confidence interval [CI], 0.08 to 1.79; p = 0.16) and within 12 months (MD 0.89, 80% CI, 0.05 to 1.74; p = 0.18). The study was designed to identify potential evidence to support the effectiveness of vitamin D3 supplementation in improving acute fracture healing. Vitamin D3 supplementation, particularly high doses, might modestly improve acute tibia or femoral shaft fracture healing in healthy adults, but confirmatory studies are required. The Vita-Shock trial was awarded the Orthopaedic Trauma Association's (OTA) Bovill Award in 2020. This award is presented annually to the authors of the most outstanding OTA Annual Meeting scientific paper. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Gerard P. Slobogean
- R Adams Cowley Shock Trauma Center, Department of OrthopaedicsUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Sofia Bzovsky
- Division of Orthopaedic Surgery, Department of SurgeryMcMaster UniversityHamiltonCanada
| | - Nathan N. O'Hara
- R Adams Cowley Shock Trauma Center, Department of OrthopaedicsUniversity of Maryland School of MedicineBaltimoreMDUSA
| | | | - Zachary D. Hannan
- R Adams Cowley Shock Trauma Center, Department of OrthopaedicsUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Haley K. Demyanovich
- R Adams Cowley Shock Trauma Center, Department of OrthopaedicsUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Daniel W. Connelly
- R Adams Cowley Shock Trauma Center, Department of OrthopaedicsUniversity of Maryland School of MedicineBaltimoreMDUSA
| | | | - Lehana Thabane
- Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonCanada
| | - Sheila Sprague
- Division of Orthopaedic Surgery, Department of SurgeryMcMaster UniversityHamiltonCanada,Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonCanada
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Huang X, Chen Y, Chen B, Zheng K, Lin C, Lin F, Luo X. Reamed versus unreamed intramedullary nailing for the treatment of femoral shaft fractures among adults: A meta-analysis of randomized controlled trials. J Orthop Sci 2022; 27:850-858. [PMID: 34303590 DOI: 10.1016/j.jos.2021.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/03/2021] [Accepted: 03/17/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this meta-analysis is to compare the merits and drawbacks between reamed intramedullary nailing (RIN) and unreamed intramedullary nailing (URIN) among adults. METHODS We comprehensively searched PubMed, MEDLINE database through the PubMed search engine, Google Scholar, Cochrane Library, Embase, VIPI (Database for Chinese Technical Periodicals), and CNKI (China National Knowledge Infrastructure) from inception to March 2020. Outcomes of interest included nonunion rates, implant failure rates, secondary procedure rates, blood loss, acute respiratory distress syndrome (ARDS) rates, and pulmonary complications rates. RESULTS Eight randomized controlled trials were included. The result of nonunion rates shows that the nonunion rate is significantly lower in the RIN group (RR = 0.20, 95% CI = 0.09-0.48, Z = 3.63, P = 0.0003). There were no significant differences for the risk of implant failure rates (RR = 0.55, 95% CI = 0.18-1.69, Z = 1.04, P = 0.30). The secondary procedure rates were significantly lower in the RIN group (RR = 0.28, 95% CI = 0.12-0.66, Z = 2.91, P = 0.004). The result shows that the blood loss of URIN group is significantly lower (RR = 145.52, 95% CI = 39.68-251.36, Z = 2.69, P = 0.007). The result shows that there was no significant difference in the ARDS rates (RR = 1.53, 95% CI = 0.37-6.29, Z = 0.59, P = 0.55) and the pulmonary complications rates between RIN group and URIN group (RR = 1.59, 95% CI = 0.61-4.17, Z = 0.94, P = 0.35). CONCLUSIONS Reamed intramedullary nailing would lead to lower nonunion rate, secondary procedure rate and more blood loss. Unreamed intramedullary nailing is related to a higher nonunion rate, secondary procedure rate and less blood loss. No significant difference is found in implant failure rate, ARDS rate and pulmonary complication rate between the two groups.
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Affiliation(s)
- Xu'an Huang
- School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Yifan Chen
- Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Bin Chen
- Department of Orthopedic Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, The Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Ke Zheng
- Department of Orthopedic Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, The Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Chaohui Lin
- Department of Orthopedic Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, The Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Fengfei Lin
- Department of Orthopedic Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, The Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China.
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Anusitviwat C, Iamthanaporn K, Tuntarattanapong P, Tangtrakulwanich B, Liabsuetrakul T. Complications after intramedullary nail fixation of pathological versus non-pathological femoral shaft fractures: a retrospective cohort study in 233 patients. Patient Saf Surg 2021; 15:29. [PMID: 34446070 PMCID: PMC8390257 DOI: 10.1186/s13037-021-00304-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative adverse events after intramedullary nailing have been reported in patients with metastatic pathological and non-pathological femoral fractures. Other consequences to be considered are readmission and reoperation. Few studies have compared the risks of postoperative adverse events, reoperation, and readmission after intramedullary nailing of pathological and non-pathological femur fractures. This study was designed to test the hypothesis that patients with pathological femoral fractures had more adverse events, readmission, and reoperation following surgical fixation than non-pathological femoral fractures. METHODS This was a retrospective observational cohort study, conducted at an academic medical center in Thailand. The data from patients with femoral shaft fractures undergoing long intramedullary nailing, from June 1, 2006, to June 30, 2020, were included. Patients who had a pathological fracture from a primary bone tumor, metabolic bone disease, or inadequate/missing information were excluded. Patients with pathological fractures from metastatic bone disease were assigned to be the pathological group whereas those with traumatic fractures were assigned to be the non-pathological group. The primary outcome was the risk of inpatient adverse events as compared between the two groups. The secondary outcome was the risk of consequences after discharge as compared between the two groups. Outcomes were analyzed by using multivariate logistic regression analysis. RESULTS The total number of patients was 48 in the pathological fracture group and 185 in the non-pathological group. There were significantly higher rates of surgical and medical adverse events in patients with pathological fractures compared to patients with non-pathological fractures. After adjusting for potential confounding factors in multivariate regression analysis, patients with pathological fractures had higher odds of both adverse surgical (adjusted OR 2.43, 95 % CI 1.15-5.13) and medical adverse events (adjusted OR 2.81, 95 % CI 1.13-7.03). CONCLUSIONS Patients with metastatic pathological femoral shaft fractures undergoing intramedullary nailing were more likely to experience postoperative adverse events than patients with non-pathological fractures.
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Affiliation(s)
- Chirathit Anusitviwat
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, 15 Karnjanavanich Road, 90110, Hat Yai, Songkhla, Thailand.
| | - Khanin Iamthanaporn
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, 15 Karnjanavanich Road, 90110, Hat Yai, Songkhla, Thailand
| | - Pakjai Tuntarattanapong
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, 15 Karnjanavanich Road, 90110, Hat Yai, Songkhla, Thailand
| | - Boonsin Tangtrakulwanich
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, 15 Karnjanavanich Road, 90110, Hat Yai, Songkhla, Thailand
| | - Tippawan Liabsuetrakul
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Albareda J, Ibarz E, Mateo J, Suñer S, Lozano C, Gómez J, Redondo B, Torres A, Herrera A, Gracia L. Are the unreamed nails indicated in diaphyseal fractures of the lower extremity? A biomechanical study. Injury 2021; 52 Suppl 4:S61-S70. [PMID: 33707035 DOI: 10.1016/j.injury.2021.02.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Intramedullary nailing is generally accepted as the first choice for the treatment of diaphyseal fractures of femur and tibia, with a gradual incease in the use of unreamed nails. Different studies during last years show controversial outcomes. Some authors strongly favor unreamed nailing, but most of the authors conclude that reamed nailing have proved to be more successful. MATERIAL AND METHODS This study simulates unreamed intramedullary nailing of four femoral and three tibial fracture types by means of Finite Element (FE) models, at early postoperative stages with a fraction of physiological loads, in order to determine whether sufficient stability is achieved, and if the extent of movements and strains at the fracture site may preclude proper consolidation. RESULTS The behavior observed in the different fracture models is very diverse. In the new biomechanical situation, loads are only transmitted through the intramedullary nail. Mean relative displacement values of fractures in the femoral bone range from 0.30 mm to 0.82 mm, depending on the fracture type. Mean relative displacement values of the tibial fractures lie between 0.18 and 0.62 mm, depending on the type of fracture. Concerning mean strains, for femoral fractures the maximum strains ranged between 12.7% and 42.3%. For tibial fractures the maximum strains ranged between 10.9% and 40.8%. CONCLUSIONS The results showed that unreamed nailing provides a very limited mechanical stability, taking into account that analyzed fracture patterns correspond to simple fracture without comminution. Therefore, unreamed nailing is not a correct indication in femoral fractures and should be an exceptional indication in open tibial fractures produced by high-energy mechanism.
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Affiliation(s)
- J Albareda
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - E Ibarz
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - J Mateo
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Miguel Servet University Hospital. Zaragoza, Spain
| | - S Suñer
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain
| | - C Lozano
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain
| | - J Gómez
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital.
| | - B Redondo
- Aragón Health Research Institute. Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - A Torres
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Department of Orthopaedic Surgery and Traumatology, Lozano Blesa University Hospital
| | - A Herrera
- Department of Surgery, University of Zaragoza. Zaragoza, Spain, Zaragoza, Spain; Aragón Health Research Institute. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
| | - L Gracia
- Department of Mechanical Engineering, University of Zaragoza. Zaragoza, Spain; Aragón Institute for Engineering Research. Zaragoza, Spain
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Zhang R, Yin Y, Li S, Hou Z, Jin L, Zhang Y. Intramedullary nailing versus a locking compression plate for humeral shaft fracture (AO/OTA 12-A and B): A retrospective study. Orthop Traumatol Surg Res 2020; 106:1391-1397. [PMID: 32089473 DOI: 10.1016/j.otsr.2019.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 08/28/2019] [Accepted: 12/16/2019] [Indexed: 02/03/2023]
Abstract
INTRODUCTION There has been great progress in surgical techniques for treating humeral shaft fractures over the past few decades. The purpose of this study was to compare the therapeutic effects of intramedullary nailing (IMN) and locking compression plate (LCP) for humeral shaft fractures (AO/OTA 12-A and B). HYPOTHESIS Compared with LCP, better therapeutic effects could be obtained with less invasive IMN. MATERIALS AND METHODS Patients with a humeral shaft fracture who received anterograde IMN or LCP fixation in our institution from December 2011 to June 2016 were reviewed in this study. They were divided into two groups according to the different fixation methods: Group A (IMN) and Group B (LCP). The surgical time, intraoperative blood loss, and complications of the patients were reviewed. Fracture healing was evaluated by radiographs performed at each follow-up. The functional outcome was assessed by the DASH (Disabilities of the Arm, Shoulder and Hand) scoring system at the final follow-up. RESULTS Thirty-four patients in Group A and forty-six patients in Group B were included in this study. Mean incision length and blood loss in Group B were greater than those in Group A (p<0.001). The average surgical times were 118.53minutes in Group A and 128.91minutes in Group B (p=0.114). The mean DASH scores were 23.76±16.78 in Group A and 22.37±15.18 in Group B (p=0.609). The complication rates were 8/34 in Group A and 7/46 in Group B, respectively (p=0.887). DISCUSSION The study hypothesis was partially confirmed. Although IMN was a less invasive technique, similar therapeutic results were obtained for humeral shaft fractures (AO/OTA 12-A and B) fixed with two surgical methods. LEVELS OF EVIDENCE III, retrospective comparative study.
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Affiliation(s)
- Ruipeng Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijazhuang, 050051, China
| | - Yingchao Yin
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijazhuang, 050051, China
| | - Shilun Li
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijazhuang, 050051, China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijazhuang, 050051, China
| | - Lin Jin
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijazhuang, 050051, China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijazhuang, 050051, China.
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Sprague S, Bzovsky S, Connelly D, Thabane L, Adachi JD, Slobogean GP. Study protocol: design and rationale for an exploratory phase II randomized controlled trial to determine optimal vitamin D 3 supplementation strategies for acute fracture healing. Pilot Feasibility Stud 2019; 5:135. [PMID: 31768262 PMCID: PMC6873563 DOI: 10.1186/s40814-019-0524-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/23/2019] [Indexed: 12/20/2022] Open
Abstract
Background Observational studies have found that 75% of healthy adult fracture patients (ages 18-50) have serum 25-hydroxyvitamin D (25(OH)D) levels < 30 ng/mL. Although lower serum 25(OH)D levels have yet to be correlated to fracture healing complications or poor fracture outcomes, many orthopedic surgeons are routinely prescribing vitamin D supplements to improve fracture healing in healthy non-osteoporotic patients. To address this gap in the literature, we propose a phase II exploratory randomized controlled trial comparing three vitamin D3 dosing regimens for early surrogate treatment response. Methods We will conduct a 4-arm blinded exploratory phase II trial in 96 adults aged 18-50 years with a closed or low-grade open (Gustilo type I or II) tibial or femoral shaft fracture. Eligible patients will be randomized in equal allocation ratio of 1:1:1:1 to one of the treatment groups: (1) 150,000 IU loading dose vitamin D3 plus daily dose placebo; (2) loading dose placebo plus 4000 IU vitamin D3 per day, (3) loading dose placebo plus 600 IU vitamin D3 per day, or (4) loading dose placebo plus daily dose placebo. The primary outcome is fracture healing, assessed as follows: (1) clinical fracture healing measured using the Function IndeX for Trauma, (2) radiographic fracture healing measured using the Radiographic Union Score for Tibial fractures, and (3) biological fracture healing measured using serum levels of cross-linked C-terminal telopeptides of type I collagen and amino-terminal procollagen propeptides of collagen type I. The main secondary outcome will be assessed by measuring serum 25(OH)D levels. All outcome analyses will be exploratory and adhere to the intention-to-treat principle. Per-protocol sensitivity analyses will also be conducted. Discussion Study results will be disseminated through a publication in an academic journal and presentations at orthopedic conferences. Study results will inform dose selection for a large definitive randomized controlled trial and provide preliminary clinical data on which dose may improve acute fracture healing outcomes in healthy adult patients (18-50 years) at 3 months. Trial registration Vita-Shock (A Blinded Exploratory Randomized Controlled Trial to Determine Optimal Vitamin D3 Supplementation Strategies for Acute Fracture Healing) was registered at ClinicalTrials.gov (identifier NCT02786498) prior to enrollment of participants.
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Affiliation(s)
- Sheila Sprague
- 1Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8 Canada.,2Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8 Canada
| | - Sofia Bzovsky
- 1Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8 Canada
| | - Daniel Connelly
- 3R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201 USA
| | - Lehana Thabane
- 2Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8 Canada
| | - Jonathan D Adachi
- 4Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4L8 Canada
| | - Gerard P Slobogean
- 3R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201 USA
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Tucker SM, Wee H, Fox E, Reid JS, Lewis GS. Parametric Finite Element Analysis of Intramedullary Nail Fixation of Proximal Femur Fractures. J Orthop Res 2019; 37:2358-2366. [PMID: 31254411 DOI: 10.1002/jor.24401] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 06/06/2019] [Indexed: 02/04/2023]
Abstract
Proximal femur fracture fixation with intramedullary nailing relies on stability at the fracture site and integrity of the fixation construct to achieve union. The biomechanics that dictate fracture site stability and implant stress depend on fracture type as well as implant features such as nail length, nail diameter, presence of distal fixation screws, and material composition of the implant. When deciding how to fix a fracture, surgeons have choices in these implant-related design variables. This study models all combinations of a range of implant variables for nine standard AO/OTA proximal femur fractures using finite element analysis. Under simulated maximum load during gait, the maximum stress in the implant and screws as well as interfragmentary motions at the fracture site in the axial and shear directions were computed. The results were separated by fracture type to show the influence of each design variable on measured biomechanical outcomes. Filling the reamed canal with the largest fitting nail diameter reduced axial and shear interfragmentary motion for all fracture types. Nail length was less predictive of shear interfragmentary motion for most simulated fracture types than other construct variables. Furthermore, gapping at the fracture site predisposed the construct to higher implant stresses and larger interfragmentary motions. Clinical significance: Biomechanical outcomes from this computational study can aid in surgical decision-making for optimizing hip fracture fixation with IM nailing. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2358-2366, 2019.
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Affiliation(s)
- Scott M Tucker
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Hwabok Wee
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Edward Fox
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Gregory S Lewis
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
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Abstract
Intramedullary nailing, as the gold standard stabilisation method of most long bones, has been tailed by its extensive use as the basic tool of investigating the immune response to trauma in many large and small animal models, as well as at the clinical setting. Over the last few decades a complex map of interactions between pro and anti-inflammatory pathways has been the result of these significant global research efforts. Parallel to the evolution of modern nailing and reaming techniques, significant developments at the fields of other disciplines relevant to trauma care, has improved the contemporary management of injured patients, challenging previous concepts and altering clinical barriers. The current article aims to summarise the current understanding of the effect of instrumenting the medullary canal after trauma, and hint on potential future directions.
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Affiliation(s)
- Nikolaos K Kanakaris
- Clinical Lead of Major Trauma Services, Leeds General Infirmary, Clarendon Wing, Level D, LS13EX, Leeds, West Yorkshire, UK.
| | - Christopher Anthony
- Trauma and Orthopaedics Yorkshire and Humber Deanery, Leeds Teaching Hospitals NHS Trust, UK.
| | | | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, UK.
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Li AB, Zhang WJ, Guo WJ, Wang XH, Jin HM, Zhao YM. Reamed versus unreamed intramedullary nailing for the treatment of femoral fractures: A meta-analysis of prospective randomized controlled trials. Medicine (Baltimore) 2016; 95:e4248. [PMID: 27442651 PMCID: PMC5265768 DOI: 10.1097/md.0000000000004248] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Intramedullary nailing is commonly used for treating femoral shaft fractures, one of the most common long bone fractures in adults. The reamed intramedullary nail is considered the standard implant for femoral fractures. This meta-analysis was performed to verify the superiority of reamed intramedullary nailing over unreamed intramedullary nailing in fractures of the femoral shaft in adults. Subgroup analysis of implant failure and secondary procedure was also performed. METHODS Electronic literature databases were used to identify relevant publications and included MEDLINE (Ovid interface), EMBASE (Ovid interface), and the Cochrane Central Register of Controlled Trials (CENTRAL; Wiley Online Library). The versions available on January 30, 2016, were utilized. Only human studies, which were designed as randomized controlled clinical trials, were included. Two authors independently evaluated the quality of original research publications and extracted data from the studies that met the criteria. RESULTS Around 8 randomized controlled trials involving 1078 patients were included. Reamed intramedullary nailing was associated with shorter time to consolidation of the fracture (SMD = -0.62, 95% CI = -0.89 to -0.35, P < 0.00001), lower secondary procedure rate (OR = 0.25, 95% CI 0.10-0.62, P = 0.003), lower nonunion rate (OR = 0.14, 95% CI = 0.05-0.40, P < 0.01), and lower delayed-union rate (OR = 0.19, 95% CI = 0.07-0.49, P < 0.01) compared to unreamed intramedullary nailing. The 2 groups showed no significant differences in risk of implant failure (OR = 0.50, 95% CI 0.14-1.74, P = 0.27), mortality risk (OR = 0.94, 95% CI 0.19-4.68, P = 0.94), risk of acute respiratory distress syndrome (ARDS; OR = 1.55, 95% CI 0.36-6.57, P = 0.55), or blood loss (SMD = 0.57, 95% CI = -0.22 to 1.36, P = 0.15). CONCLUSION Reamed intramedullary nailing is correlated with shorter time to union and lower rates of delayed-union, nonunion, and reoperation. Reamed intramedullary nailing did not increase blood loss or the rates of ARDS, implant failure, and mortality compared to unreamed intramedullary nailing. Therefore, the treatment of femoral fractures using reamed intramedullary nailing is recommended.
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Affiliation(s)
| | | | | | | | | | - You-Ming Zhao
- Department of Orthopaedics, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Correspondence: You-Ming Zhao, Department of Orthopaedics, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (e-mail: )
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Hardy BM, Yoshino O, Quail AW, Balogh ZJ. Influence of the timing of internal fixation of femur fractures during shock resuscitation on remote organ damage. ANZ J Surg 2015; 85:966-71. [PMID: 26077865 DOI: 10.1111/ans.13197] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Reamed intramedullary nailing is the gold standard for management of femur fractures. Nailing within 24 h is proven to reduce complications from ongoing bleeding, soft-tissue damage and pain. However, when combined with haemorrhagic shock, femur fracture and intramedullary nailing are associated with immune-mediated damage to remote organs. We studied whether delaying fracture fixation until resuscitation was succeeding would lead to a significant reduction in remote organ damage. METHODS Twenty male rabbits underwent closed femur fracture, haemorrhagic shock, resuscitation and either immediate nailing (group: ImmFix, n = 9), delayed nailing (group: DelFix, n = 8) or just splinting (group: NoFix, n = 3). Haemorrhagic shock was maintained for 60 min. Resuscitation was with shed blood and Hartmann's solution. Animals were euthanized 8 h after fixation; the lungs and small bowel were scored histologically by two pathologists. RESULTS Groups did not differ in weight, haemorrhage volume or magnitude of shock. At 8 h, there was no difference in end-organ damage between ImmFix and DelFix groups (11.3 ± 1.6 and 13.2 ± 1.6 versus 8.1 ± 1.3 and 12.9 ± 1.1, P = 0.26 between groups). However, the NoFix group had significantly greater end-organ damage when compared with the fixation at any time groups (17.3 ± 2.7 and 17.0 ± 3.3 versus 9.8 ± 1.1 and 13.1 ± 1, P = 0.01 between groups). CONCLUSION In this laboratory model, we have demonstrated that timely femur fracture fixation outweighs the potential harmful effects of surgery performed during haemorrhagic shock with simultaneous resuscitation. We have failed to demonstrate a difference between immediate and delayed fixation during resuscitation.
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Affiliation(s)
- Benjamin M Hardy
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Department of Traumatology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Osamu Yoshino
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Department of Traumatology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Anthony W Quail
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Department of Anaesthesia and Intensive Care, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Zsolt J Balogh
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Department of Traumatology, John Hunter Hospital, Newcastle, New South Wales, Australia
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Boesmueller S, Michel M, Hofbauer M, Platzer P. Primary cementless hip arthroplasty as a potential risk factor for non-union after long-stem revision arthroplasty in periprosthetic femoral fractures. INTERNATIONAL ORTHOPAEDICS 2014; 39:617-22. [PMID: 25128966 DOI: 10.1007/s00264-014-2489-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/29/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE In case of stem loosening in periprosthetic femoral fractures (PPFF), revision arthroplasty should be performed. The first hypothesis of this study was that advanced patient age and female gender shows higher non-union rates. The second hypothesis was that primary cementless arthroplasty is associated with a higher non-union rate compared to cemented primary hip arthroplasty. METHODS All PPFF occurring between January 2000 and June 2010 treated by revision arthroplasty were included. Multiple regression analysis was performed to identify independent variables leading to fracture non-union. RESULTS Eighty one patients (78 % female) met the inclusion criteria. In 20/81 patients (24.7 %) no adequate fracture healing could be determined on radiographs 12 months after revision surgery. Although age and female gender showed a positive correlation with bony non-union after PPFF as expected, the p-values were not statistically significant. Multiple regression analysis revealed primary cementless prosthesis (p = 0.001) to be the only independent variable associated with non-union. CONCLUSION Non-cemented primary prosthesis might be a negative predicting factor for the development of non-union after long-stem revision arthroplasty in PPFF. We therefore recommend the thorough debridement of pannus tissue thus inducing bone healing before the implantation of revision prostheses.
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Duan X, Li T, Mohammed AQ, Xiang Z. Reamed intramedullary nailing versus unreamed intramedullary nailing for shaft fracture of femur: a systematic literature review. Arch Orthop Trauma Surg 2011; 131:1445-52. [PMID: 21594571 DOI: 10.1007/s00402-011-1311-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Fractures of femoral fracture are among the most common fractures encountered in orthopedic practice. Intramedullary nailing is the treatment choice for femoral shaft fractures in adults. The objective of this article is to determine the effects of reamed intramedullary nailing versus unreamed intramedullary nailing for fracture of femoral shaft in adults. METHODS Cochrane Central Register of Controlled Trials (October 2010), PubMed (October 2010) and EMBASE (October 2010) were searched. Randomized and quasi-randomized controlled clinical trials were included. After independent study selection by two authors, data were collected and extracted independently. The methodological quality of the studies was assessed. Pooling of data was undertaken where appropriate. RESULTS Seven trials with 952 patients (965 fractures) were included. Compared with unreamed nailing, reamed nailing was significantly lower reoperation rate (RR 0.25, 95% CI 0.11-0.59, P = 0.002), lower non-union rate (RR 0.20, 95% CI 0.05-0.77, P = 0.02) and lower delay union rate(RR 0.30, 95% CI 0.14-0.64, P = 0.002). There was no significant difference when comparing reamed nailing with unreamed nailing for implant failure (RR 0.51, 95% CI 0.16-1.61, P = 0.25), mortality(RR 0.94, 95% CI 0.19-4.58, P = 0.94) and acute respiratory distress syndrome(RR 1.53, 95% CI 0.37-6.29, P = 0.55). Unreamed nailing was significantly less blood loss (SMD 119.23, 95% CI 59.04-180.43, P = 0.0001). CONCLUSION Reamed intramedullary nailing has better treatment effects than unreamed intramedullary nailing for shaft fracture of femur in adults.
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Affiliation(s)
- Xin Duan
- Department of Orthopedics, West China Hospital, Sichuan University, No 37 Guo Xue Xiang, Chengdu 610041, China.
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13
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Reaming as an adjuvant to irrigation on bacterial presence and propagation: an open, cadaveric intramedullary fracture model. J Orthop Trauma 2011; 25:325-30. [PMID: 21577065 DOI: 10.1097/bot.0b013e3182009ce5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this investigation is to evaluate the effect of intramedullary reaming on bacterial presence and propagation in an open, cadaveric intramedullary fracture model. METHODS Twelve fresh-frozen human cadaveric femurs were osteotomized and inoculated with Staphylococcus aureus, the open, cadaveric intramedullary fracture model. Low-pressure pulsed lavage irrigation was performed to irrigate the osteotomy sites. The specimens were divided into two groups of six paired specimens: CNT, irrigation only; and REAM, irrigation coupled with intramedullary reaming. Intramedullary contents were cultured at the osteotomy site and in 1-cm increments through the distal femoral metaphysis. Mean bacterial colony-forming units were compared between groups using analysis of variance. RESULTS A statistically significant higher bacterial colony-forming unit count was noted at the osteotomy site (bacterial presence) in the CNT group compared with the REAM group. In terms of bacterial propagation, when compared with the sterile osteotomy site, the CNT group demonstrated significant bacterial propagation only at the 1.1- to 2.0-cm increment and the REAM group demonstrated no significant propagation. In comparing bacterial propagation between the CNT and the REAM groups, no significant differences were noted at any distal increment. CONCLUSION In this open, cadaveric intramedullary fracture model, low-pressure pulse lavage coupled with intramedullary reaming demonstrated significantly less bacterial presence at the osteotomy site compared with irrigation without reaming. Additionally, intramedullary reaming does not appear to significantly propagate bacteria into the intramedullary canal nor into the distal metaphysis. These observations might have clinical significance.
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Abstract
BACKGROUND Meta-analysis has become accepted as a methodically rigorous research tool, and as a result, many meta-analyses have been undertaken in orthopedic trauma, the implication being that their conclusions have improved surgeons' knowledge and facilitated improved clinical care. There have been criticisms of the methodology used in a number of meta-analyses; however, there has been no previous study of the clinical usefulness of their conclusions. METHODS A study of 60 orthopedic trauma meta-analyses published during or after 2000 was undertaken. We divided the conclusions of the meta-analyses into four types depending on their innovation and potential for improving clinical care. We also separated the meta-analyses according to whether they were undertaken by the Cochrane Collaboration or by independent surgeons. RESULTS Only 4 (6.7%) of the meta-analyses contained new, clinically useful, information, and 22 (36.7%) had no conclusions at all. A further 25 (41.7%) contained conclusions that were already in the standard orthopedic trauma literature. Approximately 70% of the Cochrane Collaborations had no conclusions. CONCLUSIONS We found considerable variability in the clinical usefulness of orthopedic trauma meta-analyses, and we question the clinical usefulness of this type of research.
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Abstract
In this review we focus on the local biologic and physiologic effects of intramedullary reaming of long bones. Among the topics discussed are the consequences for vascularity, as well as the pathophysiology of intramedullary pressure generation and temperature increase. Reaming techniques and their suggested effects on bone formation are outlined. Moreover, techniques for avoiding local and systemic complications are summarized.
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Affiliation(s)
- Roman Pfeifer
- Department of Orthopaedic and Trauma Surgery, University of Aachen Medical Center, 30 Pauwels Street, 52074 Aachen, Germany.
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Goplen G, Wilson JA, McAffrey M, Deluzio K, Leighton R. A cadaver model evaluating femoral intramedullary reaming: a comparison between new reamer design (Pressure Sentinel) and a novel suction/irrigation reamer (RIA). Injury 2010; 41 Suppl 2:S38-42. [PMID: 21144925 DOI: 10.1016/s0020-1383(10)70007-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the intramedullary pressures developed during reaming of cadaveric femurs with the Synthes Reamer/Irrigator/Aspirator (RIA) reamer and the Zimmer Pressure Sentinel (PS) reamer, controlling for the force and speed of reaming. METHOD Fifteen matched pairs of frozen unpreserved femurs were used in the study. Two pressure transducers and two thermocouples were screwed into holes drilled into the femoral shaft. The femurs were stabilized in the vertical position by mechanically attaching them to a custom jig equipped with a load cell to detect the vertical component of force applied to the reamer. Proximally a linear voltage displacement transducer (LVDT) was attached to the reamer to record the continuous position of the reamer. All femurs were reamed to a diameter 2 mm larger than the narrowest point of the canal. Proximal and distal pressures, proximal and distal temperatures, applied vertical force and displacement were measured continuously throughout the reaming process. Maximum and minimum, and average proximal and distal pressures for each reamer were obtained and compared using paired t-tests. Averages were also calculated and compared in the same manner. A p-value of <0.05 was considered statistically significant. RESULTS The maximum, minimum and average intramedullary pressures during reaming were significantly lower with the RIA system than the PS reamer. In general, the pressures produced by the RIA system were consistently below atmospheric pressure for the majority of the reaming time. This was not true for the PS system. No appreciable temperature changes were observed during any of the trials. CONCLUSION The RIA reaming system significantly reduces the intramedullary pressures produced during the reaming process compared to the PS reaming system.
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Affiliation(s)
- Gordon Goplen
- Faculty of Medicine, Division of Orthopedic Surgery, University of Alberta, Edmonton, Alberta, Canada.
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Wild M, Gehrmann S, Jungbluth P, Hakimi M, Thelen S, Betsch M, Windolf J, Wenda K. Treatment strategies for intramedullary nailing of femoral shaft fractures. Orthopedics 2010; 33:726. [PMID: 20954660 DOI: 10.3928/01477447-20100826-15] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Intramedullary nailing has become the gold standard to treat femoral shaft fractures. It is unknown which nailing technique orthopedic surgeons prefer. The goal of this study was to determine current techniques and perioperative complications of intramedullary nailing of diaphyseal femoral fractures. Fifty-one institutions in 26 countries participated in an international survey to assess detailed descriptions of preferred operative strategies and perioperative complications. Altogether, 517 cases of diaphyseal femoral fractures were collected. The Internet-based survey incorporated information about fracture classification, time to operation, Injury Severity Score, type of nail, and operative technique, as well as perioperative complications such as infection, femoral neck fracture, and hardware failure. The preferred position for implantation was supine (91.1%). Most surgeons used a traction table (57.1%) and an antegrade implantation technique (84.5%). Intraoperative fractures of the femoral neck occurred in 1.2% of cases when a traction table was used and in 0.2% if no traction table was used, but without statistical significance (P>.16). In 59.2% of the cases, an isolated femur fracture was present, while the rest sustained multiple injuries. In polytrauma patients and patients with severe thorax injuries, most surgeons chose a delayed treatment with intramedullary femoral nails. Interestingly, 38.0% of the patients with severe thorax injuries were treated on the first day with intramedullary femoral nails. The total rate of complications for intramedullary femoral nailing was low (4.9%), but a high rate of intraoperative femoral neck fractures was observed (1.4%).
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Affiliation(s)
- Michael Wild
- Department of Trauma and Hand Surgery, Heinrich Heine University Hospital Düsseldorf, Germany
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18
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Gross T, Huettl T, Audigé L, Frey C, Monesi M, Seibert FJ, Messmer P. How comparable is so-called standard fracture fixation with an identical implant? A prospective experience with the antegrade femoral nail in South Africa and Europe. Injury 2010; 41:388-95. [PMID: 19900673 DOI: 10.1016/j.injury.2009.10.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 07/01/2009] [Accepted: 10/12/2009] [Indexed: 02/02/2023]
Abstract
BACKGROUND The utilisation and consequences of standardised operative procedures may importantly differ between different healthcare systems. This is the first investigation comparing the treatment and outcome of femoral shaft fractures stabilised with an identical implant between trauma centres in 2 continents (Europe, EU and South Africa, SA). METHODS Following standardised introduction of the technique, the prospective, observational multicentre study enrolled 175 patients who underwent intramedullary fracture fixation using the antegrade femoral nail (AFN) for femoral shaft fractures. Eleven EU hospitals recruited 86 patients and 1 SA centre 89 patients in the study period. Comparison of epidemiologic data, operative characteristics as well as subjective (e.g., pain, SF-36) and objective (e.g., X-ray, range of motion [ROM]) 3-month and 1-year outcomes were performed (p<0.05). RESULTS Compared to EU centres, several significant differences were observed in SA: (1) on average, patients operated on were younger, had less concomitant diseases and had more severe open fractures; (2) operative stabilisation was more often undertaken by young, unsupervised residents, with shorter operating and intraoperative fluoroscopy times; (3) mean hospital stay was shorter, with less recorded complications, but a higher loss to follow-up rate. Non- or malunion rates and subjective outcomes were similar for both groups, with the physical component of the SF-36 at the 1-year follow-up not fully restoring to baseline values. CONCLUSIONS Our investigation demonstrates the importance of several major differences between 2 different regions of the world in the treatment of femoral shaft fractures, despite involving only high level trauma centres and using an identical implant. The intercontinental comparison of results from clinical studies should be interpreted very carefully considering the heterogeneity of populations and clinical settings.
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Affiliation(s)
- Thomas Gross
- Computer Assisted Radiology & Surgery, University Hospital Basel, Realpstrasse 54, CH-4057 Basel, Switzerland.
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20
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Reaming does not add significant time to intramedullary nailing of diaphyseal fractures of the tibia and femur. ACTA ACUST UNITED AC 2009; 67:727-34. [PMID: 19820578 DOI: 10.1097/ta.0b013e31819db55c] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Reamed intramedullary nailing is the current gold standard for the treatment of diaphyseal fractures of the femur and tibia. Current concepts of orthopedic damage control surgery for patients with multiple injuries have placed an emphasis on appropriate surgical timing, limiting blood loss, and the duration of the initial operative procedure(s). Proponents of unreamed nailing have stated that reaming places polytraumatized patients "at risk," in part because it adds to the length of the surgical procedure and may exacerbate the severity of a patient's pulmonary injury. The purpose of this study was to determine how many minutes reaming actually takes and what percentage of operative time reaming comprises during intramedullary nailing of femoral and tibial shaft fractures. METHODS Intraoperative timing data were collected prospectively on a total of 52 patients with 54 fractures (21 femoral and 33 tibial) who underwent reamed intramedullary nailing of acute closed or open femoral or tibial shaft fractures over a 10-month period. Total operating room, surgical, and reaming times were collected. RESULTS The average reaming time for femur and tibia fractures was 6.9 minutes and 7 minutes, respectively. On average, reaming accounted for 4.9% of the surgical time and 3.2% of the total operating room time for femur fractures and 4.9% of the surgical time and 3.4% of the total operating room for tibia fractures. CONCLUSION Our results show that reaming comprises a small percentage of the operative time and the total time a patient spends in the operating room.
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Karadimas EJ, Papadimitriou G, Theodoratos G, Papanikolaou A, Maris J. The effectiveness of the antegrade reamed technique: the experience and complications from 415 traumatic femoral shaft fractures. Strategies Trauma Limb Reconstr 2009; 4:113-21. [PMID: 19936887 PMCID: PMC2787205 DOI: 10.1007/s11751-009-0071-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Accepted: 11/08/2009] [Indexed: 02/06/2023] Open
Abstract
This retrospective study presents the experience gained through use of reamed femoral nails and reports results and respective complications. This study included 415 femur fractures (312 men and 101 women with a mean age of 27.8 years) that were treated from 1993 to 2004. The fractures were classified according to AO, and 74 open fractures were included and typed according to the Gustilo classification. Dynamic nailing was performed for nearly all type A fractures and static nailing for types B and C. After a mean follow-up of 1.5 years, union rate was 97.8%. The complications were: 9 non-unions, 14 delayed-unions, 4 torsional malunions, 6 limb length discrepancies (shortening) and 30 nerve pareses due to traction. Deep venous thrombosis (DVT) occurred below the knee in 4 patients, while there were recorded 3 pulmonary and 2 fat embolisms, 1 superficial and 1 deep infection. There were 28 broken screws identified postoperatively. Logistic regression analysis revealed that type B and C were associated with increased risk of complications, with respective odds ratios of 3.1 (95% CI = 1.3–7.2, P = 0.011) and 4.3 (95% CI = 1.8–10.3, P = 0.001) when compared to type A patterns. All patients returned to their activities in a mean time of 10 months. Intramedullary nailing is still the treatment of choice for femoral shaft fractures, but knowledge of potential complications and their association with certain fracture patterns is needed.
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Abstract
In order to evaluate the impact of simultaneous intramedullary nailing in patients with bilateral femoral fractures on systemic complications a comprehensive review of the literature was performed. Four studies reporting the results of 197 patients following trauma were analysed. The mean Injury Severity Score was 20.6 (range, 9-75). According to the data available, reamed intramedullary nailing was performed in 96% of the cases. The incidence of fat embolism was 4.1%, ARDS 14.6% and pulmonary embolism 6.9%. The overall mortality was 6%. The mean hospital stay was 17.9 days (range, 4-108). Bilateral femoral fractures have a high risk of complications and mortality. Damage control surgery should be considered in these cases where the clinician anticipates the development of systemic complications.
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Abstract
Over the years giant steps have been made in the evolution of fracture fixation and the overall clinical care of patients. Better understanding of the physiological response to injury, bone biology, biomechanics and implants has led to early mobilisation of patients. A significant reduction in complications during the pre-operative and post-operative phases has also been observed, producing better functional results. A number of innovations have contributed to these improved outcomes and this article reports on the advances made in osteosynthesis and fracture care.
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Nichols TA, Sagi HC, Weber TG, Guiot BH. An Alternative Source of Autograft Bone for Spinal Fusion: the Femur: Technical Case Report. Oper Neurosurg (Hagerstown) 2008; 62:E179; discussion E179. [PMID: 18424957 DOI: 10.1227/01.neu.0000317390.21927.ad] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
Objective:
Autograft bone obtained from the iliac crest remains the “gold standard” for spinal fusion. For various reasons, including previous harvesting or pelvic dysmorphism, the iliac crest bone graft may not be available to the spinal surgeon. We present a novel use of a common orthopedic procedure, intramedullary reaming, for obtaining autograft for revision spinal fusion.
Methods:
A 47-year-old woman presented with failed back syndrome after multiple lumbar surgeries with previous bilateral iliac crest bone harvest. A commercially available reaming system (Synthes Reamer-Irrigator-Aspirator; Synthes USA, West Chester, PA) was introduced into the left intramedullary canal of the femur while the patient remained in the prone position. Using continuous irrigation and aspiration, the reaming debris was collected and used as autograft for the subsequent spinal fusion.
Results:
The patient underwent a successful L4–L5, L5–S1 transforaminal lumbar inter-body fusion with L3–S1 pedicle screw fixation. No complications from the femoral reaming were observed, and 6-month follow-up x-rays demonstrated osseous fusion.
Conclusion:
Femoral reaming provides an alternative source of autograft bone when other sources are unavailable.
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Affiliation(s)
- Tann A. Nichols
- Department of Neurological Surgery
- Rehabilitation, University of South Florida, Tampa, Florida
| | | | | | - Bernard H. Guiot
- Department of Neurological Surgery
- Rehabilitation, University of South Florida, Tampa, Florida
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Higgins TF, Casey V, Bachus K. Cortical heat generation using an irrigating/aspirating single-pass reaming vs conventional stepwise reaming. J Orthop Trauma 2007; 21:192-7. [PMID: 17473756 DOI: 10.1097/bot.0b013e318038d952] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the heat generation and pressure generation of a prototype irrigating aspirating intramedullary reaming system to traditional stepwise reaming. DESIGN This in vitro study used 8 pairs of fresh-frozen human cadaver tibias. Thermocouples were mounted in the mid-diaphysis and distal diaphysis. A pressure transducer was placed distally to assess intramedullary pressure, a load cell measured axial load was applied by the surgeon, and the entire construct was placed in a 37 degrees C saline bath. One specimen from each pair underwent single-pass reaming with the prototype reamer irrigator aspirator (RIA), and the contralateral limb underwent standard stepwise reaming. All variables were recorded. RESULTS There were no significant differences in pressure applied to the load cells during reaming. The maximum temperatures reached in the distal diaphysis in the RIA group (42.0 +/- 9.1 degrees C) were significantly lower (P = 0.025) than in the standard reaming group (58.7 +/- 15.9 degrees C). The maximum pressure generated in the distal tibia in the RIA group (32.7 +/- 39.4 kPa) was significantly higher (P = 0.019) than in the standard reaming group (17.0 +/- 32.6 kPa). CONCLUSIONS This study demonstrated substantially decreased temperatures with the RIA prototype when compared with standard stepwise reaming. It appears that the continuous flow of room temperature saline irrigant into the system manages to cool the cortical bone, despite the aggressive nature of a single-pass reaming method. However, in this model, contrary to the findings of other studies, the RIA system did generate higher pressures in the distal tibial metaphysis, perhaps as a result of congestion within the outflow of the RIA system. The results of this study confirm that cortical heat generation is not a problem but definitely indicate further development of this prototype aspirator function is warranted, followed by careful in vivo evaluation.
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Affiliation(s)
- Thomas F Higgins
- University of Utah Department of Orthopaedics, Salt Lake City, Utah 84108, USA.
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Bong MR, Kummer FJ, Koval KJ, Egol KA. Intramedullary nailing of the lower extremity: biomechanics and biology. J Am Acad Orthop Surg 2007; 15:97-106. [PMID: 17277256 DOI: 10.5435/00124635-200702000-00004] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The intramedullary nail or rod is commonly used for long-bone fracture fixation and has become the standard treatment of most long-bone diaphyseal and selected metaphyseal fractures. To best understand use of the intramedullary nail, a general knowledge of nail biomechanics and biology is helpful. These implants are introduced into the bone remote to the fracture site and share compressive, bending, and torsional loads with the surrounding osseous structures. Intramedullary nails function as internal splints that allow for secondary fracture healing. Like other metallic fracture fixation implants, a nail is subject to fatigue and can eventually break if bone healing does not occur. Intrinsic characteristics that affect nail biomechanics include its material properties, cross-sectional shape, anterior bow, and diameter. Extrinsic factors, such as reaming of the medullary canal, fracture stability (comminution), and the use and location of locking bolts also affect fixation biomechanics. Although reaming and the insertion of intramedullary nails can have early deleterious effects on endosteal and cortical blood flow, canal reaming appears to have several positive effects on the fracture site, such as increasing extraosseous circulation, which is important for bone healing.
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Affiliation(s)
- Matthew R Bong
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Schmidmaier G, Herrmann S, Green J, Weber T, Scharfenberger A, Haas NP, Wildemann B. Quantitative assessment of growth factors in reaming aspirate, iliac crest, and platelet preparation. Bone 2006; 39:1156-1163. [PMID: 16863704 DOI: 10.1016/j.bone.2006.05.023] [Citation(s) in RCA: 177] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Revised: 04/24/2006] [Accepted: 05/22/2006] [Indexed: 10/24/2022]
Abstract
Large bony defects and non-unions are still a complication in trauma and orthopedic surgery. Treatment strategies include the use of autogenous materials (iliac crest), allogenic bone, bone substitutes, and currently stimulation with growth factors such as BMP-2, BMP-7 or the growth factors containing platelet-rich plasma (PRP). Another source of bone graft material might be the cuttings produced during intramedullary reaming. The aim of this study was to compare the quantity of various growth factors found within iliac crest, bony reaming debris, reaming irrigation fluid, and platelet-rich plasma. Iliac crest and reaming debris and irrigation samples were harvested during surgery. PRP was prepared from blood. The growth factors in the bony materials (iliac crest or reaming debris) and of the liquid materials (platelet-poor plasma (PPP), platelet-rich plasma (PRP) or reaming irrigation) were compared. Elevated levels of FGFa, PDGF, IGF-I, TGF-beta1 and BMP-2 were measured in the reaming debris as compared to iliac crest curettings. However, VEGF and FGFb were significantly lower in the reaming debris than from iliac crest samples. In comparing PRP and PPP all detectable growth factors, except IGF-I, were enhanced in the platelet-rich plasma. In the reaming irrigation FGFa (no measurable value in the PRP) and FGFb were higher, but VEGF, PDGF, IGF-I, TGF-beta1 and BMP-2 were lower compared to PRP. BMP-4 was not measurable in any sample. The bony reaming debris is a rich source of growth factors with a content comparable to that from iliac crest. The irrigation fluid from the reaming also contains growth factors.
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Affiliation(s)
- G Schmidmaier
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany.
| | - S Herrmann
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - J Green
- Synthes, Portland, OR 97225, USA
| | - T Weber
- Methodist Hospital, Indianapolis, IN 46202, USA
| | | | - N P Haas
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - B Wildemann
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
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Rixen D, Sauerland S, Oestern HJ, Bouillon B. [Management strategies in the first operative phase after long-bone injury of the lower extremity in multiple-injured patients. A systematic literature review]. Unfallchirurg 2006; 108:829-38, 840-2. [PMID: 16180003 DOI: 10.1007/s00113-005-1012-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Lower extremity injuries make up a substantial proportion of the injuries in multiply injured patients. The aim of this systematic literature analysis was to give an overview of the levels of evidence for different management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients to enable, in the presence of adequate evidence, the development of clinical management corridors or, if the evidence was found to be inadequate, to document the necessity for scientific proof. METHODS Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (EL 1 to 5 according to the Oxford system). RESULTS The necessity for primary or secondary definitive osteosynthesis of femur/tibia shaft fractures is still a matter of discussion. Intramedullary nailing is the preferred operative procedure for definitive treatment of femur shaft fractures. Stabilization of proximal and distal femur and tibia fractures is predominantly based on expert opinion. According to the literature, perioperative antibiotic prophylaxis is essential in fracture treatment. CONCLUSION Numerous comparative studies (EL 2) dealing with management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients are available, but there are only a few randomized studies. Based on the available data, it is possible to develop a rational therapy for this patient population.
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Affiliation(s)
- D Rixen
- Klinik für Unfallchirurgie, Lehrstuhl der Universität Witten/Herdecke, Klinikum Köln-Merheim.
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