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Nino S, Courington R, Brooks P, Langford J, Haidukewych G. Retrograde Nailing for Extremely Proximal Fractures of the Femoral Shaft. J Orthop Trauma 2023; 37:346-350. [PMID: 36821474 DOI: 10.1097/bot.0000000000002586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES To report the results of retrograde intramedullary nailing (RIMN) for the treatment of extremely proximal femur fractures. DESIGN Retrospective cohort study. SETTING Level I trauma center. PATIENTS/PARTICIPANTS 63 patients with femoral shaft fractures involving the anatomic region within 10 centimeters of the inferior border of the lesser trochanter, which were treated with retrograde intramedullary nailing. INTERVENTION Retrograde intramedullary femoral nail. MAIN OUTCOME MEASUREMENTS Time to union, nonunion, malunion, and unplanned reoperation. RESULTS Between 2009 and 2020, 63 fractures were followed up to fracture union, reoperation, or a minimum of 1 year clinically. The mean follow-up was 32 months, and 48 (76%) of the patients were followed up beyond 1 year clinically. The mean patient age was 34 years (range 18-84 years), and the mean BMI was 27 (range 14-45) kg/m 2 . Forty (64%) patients were polytraumatized. Clinical and radiographic union was achieved in 59 (94%) fractures after index operation at a mean time to union of 22 weeks (range 9-51 weeks). Delayed union requiring nail dynamization occurred in 1 (2%) instance. Malreduction was noted in 1 (2%) patient with a 12-degree flexion deformity that resulted in nonunion. In total, there were 3 (5%) nonunions requiring revision surgery, 1 treated with retrograde exchange nailing and 2 revised to cephalomedullary nails; all were united after revision. CONCLUSIONS Retrograde intramedullary nailing can be an effective treatment strategy for extremely proximal femur fractures when necessary. Our series demonstrated a high rate of union and a low rate of malalignment and complications. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Degenhart C, Engelhardt L, Niemeyer F, Erne F, Braun B, Gebhard F, Schütze K. Computer-Based Mechanobiological Fracture Healing Model Predicts Non-Union of Surgically Treated Diaphyseal Femur Fractures. J Clin Med 2023; 12:jcm12103461. [PMID: 37240567 DOI: 10.3390/jcm12103461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/04/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
As non-unions are still common, a predictive assessment of healing complications could enable immediate intervention before negative impacts for the patient occur. The aim of this pilot study was to predict consolidation with the help of a numerical simulation model. A total of 32 simulations of patients with closed diaphyseal femoral shaft fractures treated by intramedullary nailing (PFNA long, FRN, LFN, and DePuy Synthes) were performed by creating 3D volume models based on biplanar postoperative radiographs. An established fracture healing model, which describes the changes in tissue distribution at the fracture site, was used to predict the individual healing process based on the surgical treatment performed and full weight bearing. The assumed consolidation as well as the bridging dates were retrospectively correlated with the clinical and radiological healing processes. The simulation correctly predicted 23 uncomplicated healing fractures. Three patients showed healing potential according to the simulation, but clinically turned out to be non-unions. Four out of six non-unions were correctly detected as non-unions by the simulation, and two simulations were wrongfully diagnosed as non-unions. Further adjustments of the simulation algorithm for human fracture healing and a larger cohort are necessary. However, these first results show a promising approach towards an individualized prognosis of fracture healing based on biomechanical factors.
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Affiliation(s)
- Christina Degenhart
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Lucas Engelhardt
- OSORA-Medical Fracture Analytics, Helmholtzstr. 20, 89081 Ulm, Germany
| | - Frank Niemeyer
- OSORA-Medical Fracture Analytics, Helmholtzstr. 20, 89081 Ulm, Germany
| | - Felix Erne
- Department of Trauma and Reconstructive Surgery, Eberhard-Karls-University Tuebingen, BG Unfallklinik, 72076 Tuebingen, Germany
| | - Benedikt Braun
- Department of Trauma and Reconstructive Surgery, Eberhard-Karls-University Tuebingen, BG Unfallklinik, 72076 Tuebingen, Germany
| | - Florian Gebhard
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Konrad Schütze
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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Panteli M, Vun JSH, West RM, Howard A, Pountos I, Giannoudis PV. Subtrochanteric femoral fractures and intramedullary nailing complications: a comparison of two implants. J Orthop Traumatol 2022; 23:27. [PMID: 35764711 PMCID: PMC9240121 DOI: 10.1186/s10195-022-00645-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 05/21/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Intramedullary (IM) nails are considered the 'gold' standard treatment for subtrochanteric femoral fractures. The incidence and risk factors for re-operation in subtrochanteric fractures remain unclear. Furthermore, no studies have compared the outcomes of different nailing systems used to treat subtrochanteric fractures in the same study population. AIMS/OBJECTIVES Our study aimed to (i) investigate the cumulative incidence and factors associated with an increased risk of re-operation in subtrochanteric fractures treated with a long intramedullary (IM) nail, (ii) compare the outcomes of subtrochanteric fractures treated with long Affixus and Gamma nails, and (iii) establish whether the addition of a proximal anti-rotation screw in the Affixus nail confers any clinical benefit. METHODS A retrospective review of all adult patients admitted to a level 1 trauma centre with a subtrochanteric femur fracture treated with a long cephalomedullary IM nail over an 8-year period was conducted. Exclusion criteria were primary surgery performed at another institution, prophylactic nailing because of tumours, incomplete fractures, and patients who were lost to follow-up or died before fracture healing. Data variables were assessed for normality prior to determining the use of either parametric or non-parametric tests. Logistic regression analysis was performed to identify potential factors associated with re-operation. For the comparison between the two nail types, patients were matched into two groups of 119 each by age (10-year intervals), gender and mechanism of injury (low energy, high energy and pathological fractures). A p-value < 0.05 was considered significant. The Kaplan-Meier nail survival curve was used to demonstrate the survival of each nail. Data were analysed using the statistical package R (R version 3.6.0). RESULTS A total of 309 subtrochanteric fractures were treated with a distally locked long IM nail (re-operation rate: 22.33%) over an 8-year period. Logistic regression identified six factors associated with an increased risk of re-operation, including age < 75 years old, use of a long Gamma nail, pre-injury coxa-vara femoral neck shaft angles, an immediate post-operative reduction angle of > 10° varus, deep wound infection and non-union. Following matching, we compared the two long cephalomedullary nailing systems used (Gamma versus Affixus nail). The only differences identified from the unadjusted analysis were a higher overall incidence of nail failure in Gamma nails due to any cause, re-operation, and impingement of the nail tip distally against the anterior femoral cortex. When we corrected for covariates, no significant differences remained evident between the two nails. From the Kaplan-Meier nail survival curves, however, the Affixus nail demonstrated better survivorship up to 5 years post-implantation in terms of nail failure and re-operation for all causes. Finally, the addition of a proximal anti-rotation screw in the Affixus nail did not seem to confer any benefit. CONCLUSION We reported a 22.3% re-operation rate in our cohort of subtrochanteric fractures treated with a long IM nail. We have identified six risk factors associated with re-operation: age < 75 years old, pre-injury femoral neck shaft angle, choice of nail, varus reduction angle, fracture-related infection and non-union. The addition of a proximal anti-rotation screw in the Affixus nail did not confer any benefit.
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Affiliation(s)
- Michalis Panteli
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level D, Great George Street, Leeds, LS1 3EX, West Yorkshire, UK. .,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK. .,Leeds Orthopaedic & Trauma Sciences, Leeds General Infirmary, University of Leeds, Leeds, UK.
| | - James S H Vun
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level D, Great George Street, Leeds, LS1 3EX, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Orthopaedic & Trauma Sciences, Leeds General Infirmary, University of Leeds, Leeds, UK
| | - Robert M West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Anthony Howard
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level D, Great George Street, Leeds, LS1 3EX, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Orthopaedic & Trauma Sciences, Leeds General Infirmary, University of Leeds, Leeds, UK
| | - Ippokratis Pountos
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level D, Great George Street, Leeds, LS1 3EX, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level D, Great George Street, Leeds, LS1 3EX, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Orthopaedic & Trauma Sciences, Leeds General Infirmary, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
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Yang J, Zhang X, Liang W, Chen G, Ma Y, Zhou Y, Fen R, Jiang K. Efficacy of adjuvant treatment for fracture nonunion/delayed union: a network meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2022; 23:481. [PMID: 35597937 PMCID: PMC9123731 DOI: 10.1186/s12891-022-05407-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/18/2022] [Indexed: 11/24/2022] Open
Abstract
Background Fracture nonunion/delayed union seriously affects physical and mental health and quality of life. The aim of this study was to evaluate the relative efficacy of different adjuvant treatments for nonunion/delayed union by network meta-analysis. Methods A comprehensive search was performed to identify randomized controlled trials (RCTs) evaluating adjuvant treatment in the management of nonunion/delayed union. A network meta-analysis reporting on healing rate, healing time, and adverse effect (AE) outcomes was conducted to assess and compare different interventions. Results Thirty studies were included in the analysis. For the healing rate outcome, bone marrow aspirate (BMA) + autologous cancellous bone (ACB) was found to be significantly better than ACB alone (odds ratio: 0.12; 95% confidence interval: 0.03, 0.59). In the ranking results, BMA+ platelet-rich plasma (PRP) (96%), BMA + ACB (90%), and BMA alone (82%) showed relative advantages in the healing rate. Low-intensity pulsed ultrasonography (LIUS) intervention significantly shortened the healing time compared with ACB (SMD: -9.26; 95% CI: − 14.64, − 3.87). LIUS (100%), BMA + PRP (74%), and bone morphogenetic proteins (BMPs) (69%) have relative advantages. Compared with the control, electromagnetic field (EMF) (OR: 13.21; 95% CI: 1.58, 110.40) and extracorporeal shock wave (ESWT) (OR: 4.90; 95% CI: 1.38, 17.43) had a higher AE risk. Conclusions Among the current intervention strategies, BMA in combination with PRP and ACB can improve the healing rate of nonunion/delayed union. LIUS can significantly shorten the healing time. EMF and ESWT may have a high risk of AE. However, large-scale, well-designed studies are still needed to confirm the results. Trial registration Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05407-5.
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Affiliation(s)
- Jun Yang
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China
| | - Xiangmin Zhang
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China
| | - Wangbo Liang
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China.
| | - Guo Chen
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China.
| | - Yanbo Ma
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China
| | - Yonghua Zhou
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China
| | - Rong Fen
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China
| | - Kaichang Jiang
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China
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