Comparative study of 567 cases

INTRODUCTION

Proximal femur fractures in elderly patients pose a common problem that requires surgical management. The main objective of this study was to compare the results of treatment by locked plate (LP) and by anterograde (AIN) or retrograde (RIN) intramedullary nailing. The secondary objective was to analyze the complications related to each group. The hypothesis of this study was that the radiological and clinical results of each group were comparable.

MATERIALS AND METHODS

The data of 438 patients from 8 centers were studied retrospectively with 365 LP and 69 cases of intramedullary nailing (49 AIN and 20 RIN). The groups were comparable in terms of mean age (75±2years), mean preoperative Parker score (5.3±0.5) and mean KOOS score (74±2). Most patients lived at home before their fracture [n=375 (86%)]. At follow-up, the joint range of motion, the KOOS and Parker scores, living premises, the time required to regain full weight-bearing, the time required for consolidation as well as the reduction alignment: frontal, sagittal, horizontal.

RESULTS

The average follow-up was: 79±2weeks (65 to 82). The functional and radiological results were comparable, although nailing allowed a faster return to weight-bearing (1±2weeks for nailing versus 7±2weeks for LP, p=0.048) and a better postoperative Parker score (5.5±0.5 for nailing versus 4.7±0.2 for LP, p=0.045). Rotational malalignment in femoral nailing was often in the direction of internal rotation, compared to the LP (p=0.045). Complications were comparable with the exception of mortality, which was more frequent for LP [22.5% in the LP group versus 13% in the nailing group (p=0.045)]. Complications were categorized as: mechanical complications 6.8% of LP, 5.7% of nailing (p>0.05), infections [11% of LP, 5.8% of nailing (p>0.05)], surgical revisions [2% of LP, 10% of nailing (p>0.05)].

DISCUSSION AND CONCLUSION

The hypothesis was refuted. These results show that nailing conferred a faster recovery of weight-bearing, a better Parker score, and is associated with a lower mortality rate. The morbidity rate is comparable between the two techniques. Indeed, when the indication for osteosynthesis by LP or by nailing is made, and both choices are technically justifiable, it would be prudent to favor the technique, which carries the least risk, which in this case is nailing. This conclusion must, however, be taken in to consideration with regard to the reduced number of nailing. A larger series of nailing, particularly retrograde, would be necessary to be able to confirm this last difference between the 2 groups.

LEVEL OF EVIDENCE

IV; comparative retrospective study.

Are extra locking bolts or fibular plating more important in extreme nailing of distal tibia fractures? A cadaveric biomechanical analysis

OBJECTIVES

In far-distal extra-articular tibia fracture "extreme" nailing, debate surrounds the relative biomechanical performance of plating the fibula compared with extra distal interlocks. This study aimed to evaluate several constructs for extreme nailing including one interlock (one medial-lateral interlock), one interlock + plate (one medial-lateral interlock with lateral fibula compression plating), and two interlocks (one medial-lateral interlock and one anterior-posterior interlock).

METHODS

Fifteen pairs of fresh cadaver legs were instrumented with a tibial nail to the physeal scar. A 1 cm segment of bone was resected from the distal tibia 3.5 cm from the joint and an oblique osteotomy was made in the distal fibula. We loaded specimens with three different distal fixation constructs (one interlock, one interlock + plate, and two interlocks) through 10,000 cycles form 100N-700 N of axial loading. Load to failure (Newtons), angulation and displacement were also measured.

RESULTS

Mean load to failure was 2092 N (one interlock), 1917 N (one interlock + plate), and 2545 N (two interlocks). Linear mixed effects modeling demonstrated that two interlocks had a load to failure 578 N higher than one interlock alone (95 % CI, 74N-1082 N; P = 0.02), but demonstrated no significant difference between one interlock and one interlock + plate. No statistically significant difference in rates or timing of displacement >2 mm or angulation >10° were demonstrated.

CONCLUSIONS

When nailing far-distal extra-articular tibia and fibula fractures, adding a second interlock provides more stability than adding a fibular plate. Distal fibula plating may have minimal biomechanical effect in extreme nailing.

Infrapatellar branch of the saphenous nerve lesion following tibial nailing: it is possible to avoid it?

BACKGROUND

Iatrogenic injury to the infrapatellar branches of saphenous nerve is a common complication following tibial nailing. This lesion seems to be directly related to the surgical approach adopted for nail insertion. The aim of the present study was to systematically review the current literature in order to assess the eventual superiority of one surgical approach for tibial nailing over the others in limiting the neurological impairment related to infrapatellar branch injury.

MATERIALS AND METHODS

The available literature was systematically screened searching papers dealing with iatrogenic injury to the infrapatellar branch of saphenous nerve after intramedullary tibial nailing. The terms "Saphenous" and "Infrapatellar branch" were used in combination with "intramedullary nailing" and "tibial fractures", supplying no limits regarding the publication year. Only publications in English were considered. Case reports, technical notes, instructional course, literature reviews, biomechanical and/ or in vitro studies were all excluded. Coleman methodological score was performed in all the retained articles.

RESULTS

Four articles matched the inclusion criteria. There were one original article and three retrospective study. Hypoesthesia and a larger extension of the area of sensory-loss were more frequently observed after vertical incision approach in three out of four articles. A trend towards a lower rate of iatrogenic nerve damage using a transverse incision was found in the remaining one, without any statistical significance.

CONCLUSIONS

In order to avoid infrapatellar nerve lesion, horizontal or oblique incisions or percutaneous approaches should be favored, although in some cases a longitudinal incision is required. Limited-extension incisions could minimize the risk and the incidence of this complication.

Should the diameter of the proximal femoral nail be large enough to fill the canal in the treatment of intertrochanteric femoral fracture in patients over fifty?

PURPOSE

Many studies have been conducted to evaluate the effects of nail shape, design, or length on the treatment of intertrochanteric fractures. However, the clinical implications of the nail diameter remain unclear.

METHODS

This study was conducted with 191 patients aged ≥ 50 years with unilateral intertrochanteric fractures treated with the same type of short cephalomedullary nail and followed for at least one year. We recorded the reduction type, tip-apex distance, cortical contact of the nail, and nail/canal diameter ratio (NCR) just distal to the locking screw. The effects of nail diameter on the clinical results were evaluated.

RESULTS

The average NCR was 68.7. The average union time was 4.78 months. Delayed union or nonunion was seen in 17 patients. Eight patients underwent additional surgery. The mean change in the modified Koval activity score was -0.84. The NCR did not significantly affect the clinical results. Comparisons of cases with NCRs above and below the average and the average - 1 standard deviation revealed no significant difference. The clinical outcome was not related to any variable associated with the nail diameter.

CONCLUSION

With this specific proximal femoral nail, a small diameter relative to that of the femoral canal had no adverse effect on the union of osteoporotic intertrochanteric fractures, even in patients with unstable fractures and those who had unsatisfactory reductions.

WEDGE FRAGMENT VARIATIONS OF TIBIAL SHAFT FRACTURES WITH INTRAMEDULLARY NAILING

Introduction

Tibial shaft fracture is the most common long-bone fracture, and the standard treatment is intramedullary (IM) nail fixation. Regardless of the development of this technique pseudoarthrosis remains prevalent.

Objectives

Evaluate the correlation between wedge fragment size and displacement, displacement of the main fragments of the 42B2 type, and pseudoarthrosis incidence.

Methods

We retrospectively assessed all patients with 42B2 type fracture treated with IM nailing between January, 2015 and December, 2019. Six radiographic parameters were defined for preoperative radiographs in the anteroposterior (AP) and lateral views. Another six parameters were defined for postoperative radiographs at three, six, and 12 months. The Radiographic Union Score for Tibial Fractures score was used to assess bone healing.

Results

Of 355 patients with tibial shaft fractures, 51 were included in the study. There were 41 (82.0%) male patients, with a mean age of 36.7 years, 37 (72.5%) had open fractures, and 28 (54.9%) had associated injuries. After statistical analysis, the factors that correlated significantly with nonunion were wedge height > 18 mm, preoperative translational displacement of the fracture in the AP view > 18 mm, and final distance of the wedge in relation to its original anatomical position after IM nailing > 5 mm.

Conclusion

Risk factors for nonunion related to the wedge and42B2 fracture are wedge height > 18 mm, initial translation in the AP view of the fracture > 18 mm, and distance > 5 mm of the wedge from its anatomical position after IM nailing. Evidence level III; Retrospective comparative study .

Complications of standard versus long cephalomedullary nails in the treatment of unstable extracapsular proximal femoral fractures: A randomized controlled trial

AIMS

To compare in a prospective randomized trial the mechanical complications in patients with unstable extracapsular proximal femur fractures without subtrochanteric extension (AO/OTA 31-A2 and 31-A3) METHODS: We prospectively studied 182 patients with unstable extracapsular proximal femur fractures without fractures lines extending more than 3 cm below the lesser trochanter, randomized to receive either a 'standard' (240 mm) nail or a long nail and followed them up for 1 year.

RESULTS

We found no difference in the incidence of mechanical or general complications between the two groups, no cut-outs, no fractures of the tip the implant, 1 cut-through and 2 malrotations in the LN group, 2 non-unions that were reoperated, one on each group. The commonest complication was blade lateral migration, 13 (14%) patients in SN and 6 (9%) in the LN. The operating time was shorter in the SN group 51 minutes compared to 67 minutes in the LN group (p=0.000075). The mortality at 1,3 and 12 months in the SN group was of 2%, 6%, 12% while in the LN group was 12%, 18% and 22%. These differences where significative at 1 (p=0.007) and 3 months (p=0.013), but not at 12 months (p=0.075).

CONCLUSIONS

We recommend the use of standard nails (240 mm) for this group of fractures, since it does not produce more mechanical complications, and it is faster, cheaper and easier to interlock distally.

Antegrade femoral nailing in the lateral decubitus position: a case series, technical tips and review of literature

BACKGROUND

Femoral intramedullary nailing is traditionally performed with the patient supine on a fracture table. We aimed to describe a case series of femoral intramedullary nailing for fracture in the lateral position, with discussion of the operative technique.

METHODS

A retrospective analysis identified 52 patients who underwent femoral intramedullary nailing performed in a lateral position without traction over a 5-year period at a single level 1 trauma center. Medical records were reviewed for demographics, blood loss including need for transfusion, operative duration, complications, length of stay, fracture union, re-operation and death.

RESULTS

There were 24 subtrochanteric, 16 peri-trochanteric and 12 diaphyseal femoral fractures. Mean operative time was 136.2 ± 101.4 min with a mean estimated blood loss of 372.5 ± 349.6 ml. Seventeen patients required blood transfusion. Mean length of stay was 10.3 ± 8.1 days. There were 3 (5.8%) surgical (compartment syndrome, infection and retained drain) and 12 (23.1%) medical complications, with a 30-day mortality rate of 3.8% (2). Mean follow-up was 9.9 ± 8.7 months. The union rate was 94.2% (49) and 3.8% (2) patients required revision fixation (hardware exchange for irritation and exchange nailing for non-union). Discharge destination was home, rehabilitation center and specialized nursing facility in 21 (40.4%), 16 (30.8%) and 15 (28.8%) patients, respectively.

DISCUSSION AND CONCLUSION

Femoral intramedullary nailing in the lateral decubitus position is a useful technique of managing peri-trochanteric, subtrochanteric and diaphyseal femoral fractures. We describe a known technique with technical tips, which has distinct advantages over traditional supine positioning especially in certain patient and fracture types. In addition, operative times, blood loss, length of stay, revision and outcomes were comparable to the literature.

[Atypical femoral fracture : Pitfalls in surgical treatment]

Atypical femoral fractures are a very rare complication after treatment with bisphosphonates. This case report describes the diagnostic criteria and some particularities of the surgical treatment. Atypical femoral fractures are typically stabilized with intramedullary nails but some pitfalls in surgical treatment, e.g. the choice of implant, have to be considered. Basically, these fractures can be treated using conventional intramedullary nails, which, however, must be used by being adapted depending on the morphology of the femur. The fact that atypical femoral fractures can occur under bisphosphonate treatment should in no way influence the indications for starting anti-osteoporotic treatment.

Intramedullary nailing vs modular megaprosthesis in extracapsular metastases of proximal femur: clinical outcomes and complication in a retrospective study

BACKGROUND

Extracapsular proximal femur metastasis could be treated by synthesis or resection and megaprosthesis. No universal accepted guidelines are present in the literature. The aim of our study is to analyze of patients with metastases in the trochanteric region of the femur treated by a single type of intramedullary nailing or hip megaprosthesis.

METHODS

We retrospectively reviewed all patients affected by extracapsular metastases of proximal femur. Anthropometric and anamnestic data, routine blood exams and complications were collected. VAS score and MSTS score was administered before the surgery, ad 1-6-12 months after surgery. An un-paired T test and Chi-square were used. Multiple linear regression and logistic regression was performed. Significance was set for p < 0.05.

RESULT

Twenty patients were assigned in intramedullary Group, twenty-five in megaprostheses Group. The mean operative time is shorter in intramedullary group. Differential shows a higher anemization in megaprostheses group (2 ± 2 vs 3.6 ± 1.3; p = 0.02). The patients of intramedullary group showed malnutrition (Albumin: 30.5 ± 6.5 vs 37.6 ± 6 g/L; p = 0.03) and pro-inflammatory state (NLR: 7.1 ± 6.7 vs 3.8 ± 2.4; p = 0.05) (PLR: 312 ± 203 vs 194 ± 99; p = 0.04) greater than megaprostheses group. The patients in intramedullary groups shows a higher functional performance score than megaprostheses group at 1 month follow-up (MSTS: 16.4 ± 6.3 vs 12.2 ± 3.7; p = 0.004). A multivariate analysis confirms the role of type of surgery (p = 0.001), surgery duration (p = 0.005) and NLR (p = 0.02) in affecting the MSTS. Globally eight complications were recorded, no statistical difference was noticed between the two groups (p = 0.7), no predictor was found at logistic analysis.

CONCLUSION

Intramedullary nailing guarantees a rapid functional recovery, compared to patients undergoing hip megaprosthesis who instead improve gradually over time. The selection of patients with poor prognosis allows the correct surgical indication of nailing, while in the case of a more favorable prognosis, the intervention of hip megaprosthesis is to be preferred.

[Shaft fractures of the lower limb in adolescents]

Shaft fractures of the lower extremities are rare during adolescence. Conservative treatment is no longer used for the upper leg and the significance is declining for the lower leg, as only minor axis deviations and malrotations of the shaft are acceptable and conservative therapy is associated with severe impairments in the daily routine; however, conservative treatment is still an option for femoral fractures in children < 3 years of age and for stable fractures of the lower leg. Various osteosynthesis procedures can be used depending on the body weight and epiphyseal maturation. Elastic stable intramedullary nailing is the first choice, followed by solid adolescent femoral or tibial nailing for higher body weights and external fixation for open or multifragmentary fractures. Plate osteosynthesis is an established alternative. Following correct surgical treatment, all fractures have movement and at least partial load-bearing stability and the results are satisfactory. Regular controls are recommended up to the end of the growth period.

How Safe is Antegrade Femoral Nailing in Ipsilateral Acetabulum Fractures Requiring Kocher-Langenbeck Approach? An Analysis of 23 Fractures

OBJECTIVE

The ipsilateral acetabulum and femur fracture (IAFF) is an uncommon entity. This combination challenges the surgeon in the optimal management of each injury component, fixation sequence, surgical approaches, implant choices and complications. Inappropriate approach for one fracture may affect the fixation of another or modify the overall outcome. In this perspective, we aim to analyze our results in patients who underwent acetabulum fixation with Kocher-Langenbeck (K-L) approach and antegrade femur nailing (AFN), emphasizing the incidence of infection, skin necrosis and heterotopic ossification (HO).

METHODS

During the five years, 22 patients with 23 IAFF (mean age of 36.5 years) were treated operatively. All the patients underwent K-L approach for acetabulum fixation and AFN for femur fracture. All the patients were treated under the supervision of a pelvi-acetabular trauma consultant. Demographic data, injury, surgical, and postoperative details were collected. The quality of acetabular reduction was evaluated using Matta's criteria. The radiological outcome, obtained at final follow-up, was graded according to Matta's criteria. Functional outcome was evaluated by Merle d'Aubigné and Postel system. HO was graded according to the Brooker system. Complications recorded were DVT, skin necrosis, infection, arthritis, HO, AVN and need for additional surgery.

RESULTS

Out of 23, 11 had posterior dislocation, 6 had quadrilateral plate injury with central protrusion and six without dislocation. Femur fractures include 9-midshaft, 4-proximal third, 3-distal third, 3-trochanteric fractures and 4-segmental fractures. There were 11 elementary and 12 associated acetabulum fractures. 21 fractures underwent staged-fixation. Single-stage fixation was done in 2. In all cases treated with staged-fixation, AFN was done first. The mean duration of follow-up was 28 months (16-57). All femur fractures united with a mean union time of 21.3 weeks (11-37). The radiological outcome was excellent in 13, good in 4, fair in 3 and poor in 3. The functional outcome was excellent in 3, good in 11, fair in 4 and poor in 4 patients. None had skin necrosis. Three patients had infection. 14 (60.8%) hips had HO, with clinically significant HO (grade 4) in 2(8.6%). Six (26%) patients had arthritic changes. Four (17.3%) hips had avascular necrosis.

CONCLUSION

AFN is a viable option in IAFFs requiring a K-L approach under the supervision of a pelvi-acetabular surgeon. This combined approach per se does not demonstrate an increased risk of infection, wound healing problems or HO.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00544-w.

Clinical outcomes of using contralateral-side laterally bent intramedullary nails in atypical femur fractures with femoral bowing

INTRODUCTION

This study aimed to evaluate the clinical outcomes of using contralateral-side laterally bent intramedullary nails (IMNs) in bowed atypical femur fractures (AFFs).

MATERIALS AND METHODS

We retrospectively reviewed bowed AFFs treated with contralateral-side laterally bent IMNs. In total, 20 patients with 25 cases of AFFs were included. Surgical outcomes including bone union time, complications, femoral bowing, and leg length discrepancy (LLD) were evaluated. We evaluated the surgical safety of performing contralateral-side intramedullary nailing with its intraoperative and postoperative complications and compared the LLD.

RESULTS

The average age was 76.8 years (range 67-86 years), and all of patients were female. There were 10 cases of complete AFFs and 15 cases of incomplete AFFs. Fourteen patients (70%) had a history of bisphosphonate (BP) use with an average of 74.5 months of its use. In the complete AFF cases, reduction of the fractures was tried to restore the patients' normal anatomical geometry. The average lateral gap was 0.6 mm (0-1 mm), and the average medial gap was 1.6 mm (1-3 mm). All cases achieved bone union without secondary intervention. There were no intraoperative fractures or postoperative complications. The average bone union time was 22.0 weeks and 9.2 weeks in complete and incomplete AFFs, respectively. The average preoperative femoral bowing seen in the coronal and sagittal planes was 10.1° and 16.1°, respectively, while the average postoperative bowing was 6.6° and 11.3°, respectively. The average change of angle was 3.5° in the coronal plane and 4.8° in the sagittal plane. The mean change of LLD was 5.7 mm.

CONCLUSION

The use of contralateral-side laterally bent IMNs in treating bowed femurs showed excellent clinical outcomes without complications. In severely bowed femurs, this technique can be safe and useful.

Broken guidewire retrieval from the hip joint: A case report

Hardware breakage during orthopaedic surgery especially closed intramedullary nailing is a nightmare for orthopaedic surgeons. During hip fracture surgery a mechanical failure of the guidewire or the reamer poses an additional risk of intrapelvic migration and neurovascular or visceral injury which can lead to devastating complications and litigation. We report a case of removal of the broken guidewire using a cannulated reamer & discectomy forceps and recommend some suggestions for prevention of this catastrophe.

Plates vs. nails in humeral shaft fractures: Do plates lead to a better shoulder function?

Background

The purpose of this study was to compare shoulder outcomes and function after humeral shaft fractures treated with plates and screws vs. antegrade nailing.

Methods

A group of 27 patients treated with plates and a group of 30 patients (previously published) who had undergone antegrade locked intramedullary nailing, all with acute humeral shaft fractures, were retrospectively compared. Final shoulder range of motion (ROM), full shoulder ROM recovery rate, functional outcomes, residual pain, complications, and elbow flexion-extension range were also analyzed.

Results

There were a total of 57 patients: 27 cases in the plate (P) group and 30 in the nail (N) group (average age, 41.9 years).There were 66.7% men in group N and 63.0% in group P. The average age was 38 years (interquartile range [IQR] 28) in group N and 37 years (IQR 55) in group P. There were no differences in follow-up between groups, which averaged 28 months (IQR 7) in group P and 30 months (IQR 2) in group N (P = .385). There was no difference in both groups in elbow flexion-extension. Group P had a full shoulder ROM (66.6% vs. 40.0%; P = .02) and excellent Rodríguez-Merchán scoring (66% vs. 40.0%; P < .01), which was significantly higher than in group N. In group P, the Constant score was 95 (IQR 9).

Conclusions

Treatment with plates in this comparative study led to a better ROM in the shoulder and fewer complications. Loss of shoulder motion may be expected after humeral shaft osteosynthesis. However, the functional scores and the healing index can be good and excellent with both techniques.

Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies

PURPOSE

This meta-analysis compares open reduction and internal fixation with a plate (ORIF) versus nailing for humeral shaft fractures with regard to union, complications, general quality of life and shoulder/elbow function.

METHODS

PubMed/Medline/Embase/CENTRAL/CINAHL was searched for observational studies and randomised clinical trials (RCT). Effect estimates were pooled across studies using random effects models. Results were presented as weighted odds ratio (OR) or risk difference (RD) with corresponding 95% confidence interval (95% CI). Subgroup analysis was performed stratified for study design (RCTs and observational studies).

RESULTS

Eighteen observational studies (4906 patients) and ten RCT's (525 patients) were included. The pooled effect estimates of observational studies were similar to those obtained from RCT's. More patients treated with nailing required re-intervention (RD 2%; OR 2.0, 95% CI 1.0-3.8) with shoulder impingement being the most predominant indication (17%). Temporary radial nerve palsy secondary to operation occurred less frequently in the nailing group (RD 2%; OR 0.4, 95% CI 0.3-0.6). Notably, all but one of the radial nerve palsies resolved spontaneously in each groups. Nailing leads to a faster time to union (mean difference - 1.9 weeks, 95% CI - 2.9 to - 0.9), lower infection rate (RD 2%; OR 0.5, 95% CI 0.3-0.7) and shorter operation duration (mean difference - 26 min, 95% CI - 37 to - 14). No differences were found regarding non-union, general quality of life, functional shoulder scores, and total upper extremity scores.

CONCLUSION

Nailing carries a lower risk of infection, postoperative radial nerve palsy, has a shorter operation duration and possibly a shorter time to union. Shoulder impingement requiring re-intervention, however, is an inherent disadvantage of nail fixation. Notably, absolute differences are small and almost all patients with radial nerve palsy recovered spontaneously. Satisfactory results can be achieved with both treatment modalities.

Double fractures of the femur: a review of 16 patients

BACKGROUND

Double ipsilateral femoral fractures account for 1-9% of femoral fractures. There is no clear advantage between single or double implant osteosynthesis. We present a series of patients with double ipsilateral femoral fractures, to address the challenges in treatment, namely the implants for osteosynthesis and complications of treatment.

MATERIALS AND METHODS

We retrospectively studied 16 patients (7 men, 9 women; mean age, 51 years) treated from January 2015 to December 2018. Motor vehicle accidents were the leading cause of injury. Types of fractures were pertrochanteric and shaft (6), pertrochanteric and distal (2), double shaft (3), neck and shaft (2), neck and distal (1), shaft and distal (1), and triple fracture including a pertrochanteric, shaft and distal (1). In five patients, two different implants were used (plate and screws, cannulated hip screws, femoral nail), whereas in 11 patients a long femoral nail was used.

RESULTS

Fourteen patients experienced union at a mean of 3 months (2-6 months). Two patients experienced nonunion: both had plate and screws osteosynthesis. One patient died 15 days after admission from polytrauma and another patient experienced central venous catheter thrombosis and pneumonia. Surgical complications (2 patients) included a thigh skin necrosis, and external fixator pin tract infection/infected non-union. Weight-bearing was delayed in all patients; full weight-bearing was allowed in 11 patients at 4 months postoperatively, and in four patients at 5 months.

CONCLUSION

Due to the rarity and the difficulty of standardization of double ipsilateral femoral fractures, there is variable information on the optimal osteosynthesis of the fractures and the outcome of the patients. It seems that closed reduction and long hip nailing is the treatment of choice, with few complications.

MIPO versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies

PURPOSE

There is no consensus on the optimal operative technique for humeral shaft fractures. This meta-analysis aims to compare minimal-invasive plate osteosynthesis (MIPO) with nail fixation for humeral shaft fractures regarding healing, complications and functional results.

METHODS

PubMed/Medline/Embase/CENTRAL/CINAHL were searched for randomized clinical trials (RCT) and observational studies comparing MIPO with nailing for humeral shaft fractures. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR), risk difference (RD), mean difference (MD) and standardized mean difference (SMD) with corresponding 95% confidence interval (95%CI). Analyses were repeated stratified by study design (RCTs and observational studies).

RESULTS

A total of 2 RCTs (87 patients) and 5 observational studies (595 patients) were included. The effects estimated in observational studies and RCTs were similar in direction and magnitude for all outcomes except operation duration. MIPO has a lower risk for non-union (RD 7%; OR 0.2, 95% CI 0.1-0.5) and re-intervention (RD 13%; OR 0.3, 95% CI 0.1-0.8). Functional shoulder (SMD 1.0, 95% CI 0.2-1.8) and elbow scores (SMD 0.4, 95% CI 0-0.8) were better among patients treated with MIPO. The risk for radial nerve palsy following surgery was equal (RD 2%; OR 0.6, 95% CI 0.3-1.2) and nerve function recovered spontaneously in all patients in both groups. No difference was detected with regard to infection, time to union and operation duration.

CONCLUSION

MIPO has a considerable lower risk for non-union and re-intervention, leads to better shoulder function and, to a lesser extent, better elbow function compared to nailing. Although nailing appears to be a viable option, the evidence suggests that MIPO should be the preferred treatment of choice. The learning curve of minimal-invasive plating should, however, be taken into account when interpreting these results.

Intramedullary Nailing Versus Plating for Proximal Tibia Fractures: A Systematic Review and Meta-analysis

INTRODUCTION

Extra-articular proximal tibia fractures make up to one-tenth of all tibia shaft fractures. Treatment options include conservative, nailing, plating and external fixation. There is no consensus on which method is superior if the patient is to be managed surgically.

MATERIALS AND METHODS

We conducted a systematic review and meta-analysis to know which definitive surgical treatment option (nailing or plating) is better for extra-articular proximal tibia fracture. We used search engines like PubMed, Embase, Scopus, Ovid Medline and Google Scholar to find articles comparing the results of nailing versus plating. We could identify only 4 articles regarding this and data was extracted and meta-analysis was done.

RESULTS

Delayed union was common in the nailing group with odds ratio of 8.29 favoring the plating group (95% CI 1.77, 38.80, p = 0.007) while malunion showed no difference in both groups. Rate of infection was higher in the plating group while anterior knee pain was common in the nailing group with odds ratio of 5.54 favoring the plating group (95% CI 1.49, 13.88, p = 0.008). Range of motion showed no difference between both groups, fractures in the nailing group united early and the difference was significant (p = 0.005, odds ratio  - 4.48) (95% CI  - 8.29,  - 1.47).The surgical duration was less in the nailing group but was not significant.

CONCLUSION

Considering lesser time for union, early weight bearing, lower chances of infection and lesser surgical duration, nailing seems to be more promising for extra articular proximal tibia fractures. Further research is required on this topic to provide a definitive evidence.

Treatment of pediatric femoral shaft fractures with elastic stable intramedullary nails versus external fixation: A meta-analysis

BACKGROUND

There is currently a debate about whether elastic stable intramedullary nails (ESIN) or external fixation (EF) is the best surgical method for treating pediatric femoral shaft fractures. We performed a meta-analysis to determine which surgical method leads to higher treatment satisfaction, lower complication rates, and reduced treatment time, to investigate whether ESIN is the preferred surgical method for treatment of pediatric femoral shaft fractures.

PATIENTS AND METHODS

Relevant databases were searched for comparative studies of ESIN versus EF for the treating pediatric femoral shaft fractures. Literature reports and quality evaluations were extracted, followed by a systematic review using RevMan 5.3 software. Treatment satisfaction at the last follow-up, primary complications, secondary complications, and relevant time indicators (operation time, hospital stay, clinical healing time, bone healing time) were analyzed.

RESULTS

A total of 22 reports were included in this meta-analysis. We found no statistical differences in the treatment satisfaction at the last follow-up between ESIN and EF for the treatment of pediatric femoral shaft fractures. A low rate of postoperative re-fracture (RR=3.58, 95% CI (1.85, 6.92), p=0.0001) and postoperative infection (RR=9.25, 95% CI (5.32, 16.11), p<0.00001), and a high risk of skin irritation (RR=0.15, 95% CI (0.06, 0.37), p<0.00001) were found in the ESIN group. No significant differences between the two approaches were found regarding malunion. A low rate of limb-length discrepancy (RR=2.41, 95% CI (1.40, 4.17), p=0.002), hospitalization (SMD=0.84, 95% CI (0.24, 1.43), p=0.006), clinical healing time (SMD=0.95, 95% CI (0.56, 1.33), p<0.00001) and bone healing time (SMD=0.89, 95% CI (0.39, 1.40), p=0.005) were found in the ESIN group, as compared to that in the EF group. No significant differences were found in fixation failure, activity limitation of the joint, and operation time between the two strategies.

DISCUSSION

ESIN should be the primary choice for the treatment of pediatric femoral shaft fractures since it has a reliable curative effect and results in a shorter hospital stay, faster fracture healing, and fewer complications. EF is recommended for fractures with serious injury of the soft tissue to avoid intramedullary infection. Double-blind high-quality randomized studies with larger sample sizes are warranted to confirm our conclusions.

LEVEL OF EVIDENCE

IV.

Retrospective, multicenter, observational study of 112 surgically treated cases of humerus metastasis

INTRODUCTION

The humerus is the second most common site for metastasis in the peripheral skeleton. These humeral metastases (HM) occur in the midshaft in 42% to 61% of cases and theproximal humerus in 32% to 45% of cases. They are often secondary to primary breast (17-31%), kidney (13-15%) or lung (11-24%) cancer. The optimal surgical treatment between intramedullary (IM) procedures, fixation or arthroplasty is still being debated.

HYPOTHESIS

We hypothesized that fixation and/or arthroplasty are safe and effective options for controlling pain and improving the patients' function.

MATERIALS AND METHODS

Between 2004 and 2016, 11 French hospitals included 112 continuous cases of HM in 54 men (49%) and 57 women (51%). The average age was 63.7±13.4 years (30-94). The HM occurred in the context of primary breast (30%), lung (23%) or kidney (21%) cancers. The HM was proximal in 35% of cases, midshaft in 59% and distal in 7% of cases. Surgery was required in 69% of patients because of a pathological fracture. The surgical procedure consisted of bundle pinning, plate fixation, arthroplasty or locked IM nailing in 6%, 11%, 14% and 69% of patients, respectively.

RESULTS

Seven patients (6%) had to be reoperated due to surgical site complications including two infections and four fractures (periprosthetic or away from implant). Twelve patients (11%) experienced a general complication. The overall survival was 16.7 months, which was negatively and significantly impacted by the occurrence of a fracture, a diaphyseal location and the type of primary cancer. At the final assessment, 75% had normal or subnormal function and more than 90% were pain-free or had less pain. The final function was not related to the occurrence of a fracture or etiology of the metastasis. In epiphyseal and metaphyseal HM, there was a trend to better function after shoulder arthroplasty than after plate fixation or IM nailing.

CONCLUSIONS

Our initial hypothesis was confirmed. Our findings were consistent with those of other published studies. Based on our findings, we recommend using static locked IM nailing with cementoplasty for mid-shaft lesions and modular arthroplasty for destructive epiphyseal or metaphyso-epiphyseal lesions. The criteria for assessing humeral fracture risk should be updated to allow the introduction of a preventative procedure, which contributes to better survival.

LEVEL OF EVIDENCE

IV, retrospective study.

plating in comminuted proximal ulna fractures - a biomechanical analysis

Background

Comminuted proximal ulna fractures are severe injuries with a high degree of instability. These injuries require surgical treatment, usually angular stable plating or double plating is performed. Nailing of proximal ulna fracture is described but not performed regularly. The aim of this study was to compare a newly developed, locked proximal ulna nail with an angular stable plate in an unstable fracture of the proximal ulna. We hypothesize, that locked nailing of the proximal ulna will provide non-inferior stability compared to locked plating.

Methods

A defect fracture distal to the coronoid was simulated in 20 sawbones. After nailing or plate osteosynthesis the constructs were tested in a servo-pneumatic testing machine under physiological joint motion (0°-90°) and cyclic loading (30 N – 300 N). Intercyclic osteotomy gap motion and plastic deformation of the constructs were analyzed using micromotion video-analysis.

Results

The locked nail showed lower osteotomy gap motion (0.50 ± 0.15 mm) compared to the angular stable plate (1.57 ± 0.37 mm, p < 0.001). At the anterior cortex the plastic deformation of the constructs was significantly lower for the locked nail (0.09 ± 0.17 mm vs. 0.39 ± 0.27 mm, p = 0.003). No statistically significant differences were observed at the posterior cortex for both parameters.

Conclusions

Nail osteosynthesis in comminuted proximal ulna fractures shows lower osteotomy gap motion and lower amount of plastic deformation compared to locking plate osteosynthesis under laboratory conditions.

Suprapatellar nailing in proximal third tibial fractures - Clinicoradiological outcome

AIMS AND OBJECTIVES

To evaluate the clinical and radiological outcome of proximal third tibia fractures managed by suprapatellar nailing with a minimum follow-up of 12 months.

METHODOLOGY

In our retrospective cohort study of 43 consecutive proximal third tibia fractures from January 2015 to September 2018 treated with intramedullary nailing through suprapatellar approach in semiextended knee position were included. The patients were followed up regularly at 6 weeks, 3 months, 4.5 months, 6 months, 12 months and every 6 months thereafter. At each visit patients were assessed for union, shortening and rotational alignment. The clinical outcome was analysed using Lower Extremity Functional Scale (LEFS) and anterior knee pain. The radiological outcomes are analysed by evaluating the radiographs for progression of fracture union and tibial alignments.

RESULTS

After fulfilling the exclusion and inclusion criteria, 43 out of 60 consecutive proximal third tibia fracture were included in the study with an average age of 38.4 years (20-71 years), follow up of 20.4 months (12-45 months) after the index procedure. The radiological union was achieved in 7.3 months (4-13 months). At the end of 1 year follow up, the average LEFS was 89.4% (60%-95%). 4 patients had Malunion - with 1 valgus and 3 anterior angulations, 8 delayed unions and 1 non-union (with bone loss- which required bone grafting). All the fractures united eventually. No incidence of anterior knee pain.

CONCLUSION

We recommend suprapatellar nailing in proximal third tibial fractures when meticulously performed using the current surgical principles and techniques with proper implant selection. It results in excellent clinical and radiological outcomes with minimal complications when compared to other modalities of management. Suprapatellar nailing is a viable option for proximal third tibia fractures due to its inherent advantages of positioning, perfect nail entry and placement. Additionally, noteworthy absence of anterior knee pain is an additional benefit of this technique.

Nailing of diaphyseal ulna fractures in adults-biomechanical evaluation of a novel implant in comparison with locked plating

Background

Adult forearm fractures require surgical treatment in most cases. Open reduction and internal fixation with plate osteosynthesis is the therapy of choice. Intramedullary fixation offers several advantages compared to plate fixation but is not routinely used. The aim of our study was to compare a newly designed ulna nail with angular stable plating in a biomechanical testing setup of an ulna shaft fracture with a diaphyseal defect.

Methods

Ten pairs of sawbones with a defect osteotomy of the ulna shaft (OTA 2U2C3) were fixed with an interlocked nail or locked plate osteosynthesis. The constructs were tested under four-point bending, torsional loading and axial loading in a servo-pneumatic testing machine to compare the stiffness of both stabilization methods.

Results

The nail constructs show lower yet sufficient bending stiffness (62.25 ± 6.64 N/mm) compared to the plate constructs (71.2 ± 5.98 N/mm, p = 0.005). The torsional loading test shows superior stiffness of the plate constructs (0.24 ± 0.03 Nm/deg vs. 0.1 ± 0.01 Nm/deg; p < 0.001), while the axial loading shows superior stiffness of the nail constructs (1028.9 ± 402.1 N/mm vs. 343.9 ± 112.6 N/mm; p < 0.001).

Conclusions

Intramedullary nailing of ulna shaft fractures obtains sufficient but lower stability in bending and torsional loading when compared to rigid angular stable plating and could be an alternative technique to plate fixation. The lower stability and the closed stabilization technique allow for a rapid periosteal healing, which is not present in stiffer constructs.

Intramedullary tibia nailing with external fixation

PURPOSE

This study introduces an intramedullary nailing technique with external fixation and aims to determine the safest position of Schanz screws for this technique.

METHODS

Patients undergoing intramedullary nailing were evaluated by computed tomography to assess the anteroposterior (AP) length of the medullary canal and the distance between the posterior cortex and the posterior border of the nail at the level of interest in the proximal and distal tibia. In this cadaveric study, screws were inserted at the level of interest, followed by a determination of the anatomical relationship between inserted screws and nearby neurovascular structures.

RESULTS

The safe area for inserting Schanz screws in the medial to lateral direction in the proximal tibia was found to be 1.5-4.5 cm distal to the knee joint line on the AP view, 1 cm anterior to the posterior cortex at the distal 4.5 cm level, and ≤ 24 mm from the posterior cortex on the lateral view. In males, the area 1.5-3.0 cm proximal to the tibial plafond and 0.5 cm anterior to the posterior cortex on the lateral view was found to be a safe zone. However, in females, the safe zone was defined as an area 1.5 cm proximal to the tibial plafond and just anterior to the posterior cortex.

CONCLUSION

This study defined the safe zones of Schanz screws for intramedullary nailing with an external fixator. These safe zones would be helpful for external fixation during intramedullary tibia nailing.

Flexible intramedullary nailing in the treatment of forearm fractures in children and adolescents, a systematic review

Background

Forearm fractures are common injuries among children and adolescents. Traditionally, they were managed conservatively with closed reduction and cast immobilization. The last decade there is an increasing trend towards operative treatment. The treatment modalities available include plate and screws, flexible intramedullary nailing and external fixation devices - rarely used nowadays. The aim of this systematic review is to investigate the indications of flexible intramedullary nailing in the childhood population, to compare its results with plating and to provide detailed information considering technical pitfalls and complications that may be encountered.

Materials and methods

An extensive search was performed in the electronic databases (PubMed, EMBASE) from their inception up to June 2019 in order articles relevant to this review to be retrieved. The search terms used were the following: forearm fracture, both-bone fracture, pediatric, nailing, fixation. 56 articles were considered suitable for inclusion.

Results

The indications for surgery are unstable and irreducible fractures, open and fractures with neurovascular compromise. As far as the fracture site is concerned, radius and ulna shaft fractures, radial head and Monteggia fractures are suitable for nailing.Although plates and nailing have comparable clinical outcomes and complication rates, flexible intramedullary nailing has the advantage of smaller incisions, less tissue disruption, shorter operative and hospital times and an ease in hardware removal.Controversy exists over the need of single or double nailing in both-bone fractures of the forearm. In addition, there is no consensus as to which is the preferred nail diameter. Yet, all the authors agree that open reduction must be considered after certain failed closed reductions in order compartment syndrome to be avoided.Flexible intramedullary nailing is not complication-free. Skin irritation, Extensor Pollicis Longus rupture, superficial radial nerve injury, delayed union or even nonunion, malunion and refractures are some of the complications that may be encountered.

Discussion

Flexible nails are excellent implants combining stability and elasticity. The procedure of passing the nails across radius and ulna is relatively simple, requiring a small learning curve. Flexible intramedullary nailing is an excellent treatment modality for the treatment of forearm fractures in children and adolescents.

Interest of nailing associated with the Masquelet technique in reconstruction of bone defect

Introduction

The Masquelet technique based on induced membrane is performed in two stages, first with generally an external fixator which is more and more relayed by an internal fixator. The aim of this study is to assess the results of stabilization by using intramedullary nailing from the first stage.

Patients and methods

Nine patients were treated for a bone defect concerning 8 femurs and one tibia. The mean size of bone defect was 9.25 cm. It was secondary to a fracture (6 case) with bone defect and two septic and aseptic pseudarthrosis. In all cases the nailing was performed at the first stage of Masquelet. Prior to cement delivery, the site was thoroughly cleaned with iterative excisions as needed. Blood count control, normal CRP and negative culture were required before cement delivery. The cement was placed around the nail and encased the bony extremity. In the second stage, after removal of the cement, the defect was fulfilled by a mixture of cortico-cancellous autogenous graft taken from the iliac crest and phosphocalcic bone substitute. The nail was not changed in any patient. In post operative the mobilization of the above and underlying joints was immediate.

Results

No sepsis was detected before the second time. Early weight bearing was allowed on average at the end of the 2 nd month. Total bearing without support was allowed at a mean of 5.5 months. All patients have consolidated. One patient had a shortening of 2.35 cm. The mean follow-up was 46.1 months. The average period to effective return to work was 21 months.

Conclusion

The nailing performed at the first stage of the induced membrane technique (IMT) gives good results. This modification does not seem to increase the risk of infection. These good results deserve to be confirmed by other studies to confirm the interests of associating nailing to IMT from the first stage.

Nailing of proximal ulna fractures: biomechanical comparison of a new locked nail with angular stable plating

PURPOSE

Proximal ulna fractures are common injuries and frequently treated with angular stable plating. This surgical option shows good functional results. Relevant drawbacks such as large soft tissue exposure, compromised blood supply of fracture fragments and disturbing osteosynthetic material are described. The aim of this study was to compare a new locked proximal ulna nail with angular stable plating in a biomechanical testing setup for extraarticular proximal ulna fractures.

METHODS

Ten pairs of sawbones with a Jupiter type IIB proximal ulna fracture (OTA 2U1A3.1) were tested after osteosynthesis with the mentioned implants in a servo-pneumatic testing machine. The testing setup simulates physiological joint motion (0°-90°) under cyclic loading (30-300 N). Primary stability and loosening of both constructs were quantified using micromotion video-analysis after 608 test cycles.

RESULTS

The micromotion analysis showed significantly higher primary stability of the locked nail (0.29 ± 0.13 mm) compared to the angular stable plate (0.97 ± 0.30 mm, p < 0.001). Both implants showed a low amount of loosening after completion of the test cycles. The construct with the locked nail (0.08 ± 0.06 mm) showed significantly lower dislocation of the fragments measured at the anterior cortex (plate 0.24 ± 0.13 mm, p < 0.001).

CONCLUSION

Nailing of proximal ulna fractures shows significantly higher primary stability and lower loosening compared to angular stable plating in our testing setup.

Repeated intramedullary stabilization following failed telescopic nail lengthening - An appropriate treatment strategy

Externally magnetic-controlled intramedullary telescopic nails for bone lengthening have recently gained popularity due to many advantages when compared to more traditional lengthening methods. Patients requiring lengthening often present with a clinical history of previous multiple surgeries increasing the risk for complications of further procedures. However, studies regarding the treatment of complications following implantation of these devices remain scarce in literature. Therefore, we report our experience with revision surgery after lengthening with a telescopic intramedullary lengthening nail. In 6 out of 20 cases (30%) of lower limb lengthening for leg length discrepancy revision surgery was necessary. Two revisions were necessary due to nail breakage while the other 4 cases required a secondary procedure for non-union. In all cases, revision surgery included standard intramedullary locking nailing with additional autologous bone grafting. The median interval between index and revision surgery was 11.5 months (range 2-15 months). Satisfying clinical results, the intended extend of lengthening and bony consolidation was observed in all 6 patients. We conclude that revision surgery using an intramedullary locking nail with autologous bone grafting after failed telescopic nail-based lengthening represents an useful salvage procedure in these cases.

Challenges in the management of floating knee injuries: Results of treatment and outcomes of 224 consecutive cases in 10 years

INTRODUCTION

Floating knee is a flail knee joint resulting from fractures of the shafts or adjacent metaphyses of the femur and the ipsilateral tibia. It is usually associated with several complications and mortality. This study was designed to present our experience with the treatment of this injury.

MATERIAL AND METHOD

This study was performed between January 2004 and December 2014. 224 cases of floating knee injuries gathered from the 34,480 lower extremities trauma files were studied, and the target information recorded. The injuries most frequently occurred in subjects between 16 and 35 years of age (60.71%), and in male subjects (85.71%). The most frequent mechanism of injury was traffic accident (92.85%). External fixation was the common type of treatment (82.14%) in emergency or as a definitive treatment. The treatment was performed within 24 h of the trauma. We performed a 36-month follow up with clinical examination, radiographs, assessing the complications, and using the Modified Cincinnati Rating System Questionnaire (MCRSQ) and the Karlström/Olerud Score (KOS) to evaluate the progression of the outcomes.

RESULTS

Early complications included 8 cases of compartment syndrome, 60 open fractures and 24 partially amputated limbs. A total amputation was performed in 3 patients. The most common late complication was heterotopic calcifications of the knee (n = 68, 30.6%). Good scores for MCRSQ and KOS were obtained only after patients were sent to a reference center for knee surgery.

CONCLUSIONS

Our experience revealed that the complication rate associated with floatingknee injuries remains high, regardless of the performed treatment. Surgeons should focus on reducing complications while treating these severe injuries.

Minimally invasive internal fixation for extra-articular distal radius fracture: Comparison between volar plate and intramedullary nail

INTRODUCTION

There are numerous internal fixation techniques for distal radius fracture, using pins, plates or nails. Some authors have developed minimally invasive procedures. The aim of the present study was to compare two minimally invasive internal fixation techniques for unstable extra-articular distal radius fracture in women over 50 years of age: volar plate (minimally invasive plate osteosynthesis: MIPO), and intramedullary nail.

HYPOTHESES

The main study hypothesis was that the incision scar left by minimally invasive internal fixation is smaller using MIPO than an intramedullary nail. The secondary hypotheses were that the two techniques do not differ in terms of pain, functional score, strength, range of motion and radiologic indices.

MATERIAL AND METHOD

The series comprised nineteen A2.2 and one A2.1 fractures in 20 female patients with a mean age of 72 years. The first 10 (group 1) received minimally invasive internal fixation of the distal radius by MIPO, and the other 10 (group 2) by intramedullary nail locked onto the distal radius epiphysis and diaphysis.

RESULTS

The main study hypothesis was confirmed: the incision scar left by minimally invasive internal fixation was smaller using MIPO than an intramedullary nail (mean, 14.3mm vs. 32.8mm). Some of the secondary hypotheses were also confirmed: there were no differences between the two techniques in terms of pain at 6 months, QuickDASH, PRWE (Patient-Reported Wrist Evaluation), range of motion or ulnar variance; two were not confirmed: pain at 6 weeks was less with intramedullary nails, and palmar slope was better with MIPO.

DISCUSSION AND CONCLUSION

The main study hypothesis was confirmed: the incision scar left by minimally invasive internal fixation was smaller using MIPO than an intramedullary nail. In conclusion, the present findings showed that internal fixation of unstable extra-articular fracture in over 50-year-olds gave better clinical results at 6 weeks using an intramedullary nail, while MIPO required smaller incision.

LEVEL OF EVIDENCE

III, retrospective study.

A computed tomography study of the fibula: morphology, morphometry, intramedullary anatomy, application prospects on intramedullary nailing

PURPOSE

The intramedullary percutaneous pinning in fractures of the lateral malleolus is a technique of osteosynthesis that can reduce complications of ORIF. Our study describes the morphology and the morphometry of the fibula, in particular intramedullary, so as to specify the best fibular nail features.

METHODS

We conducted a retrospective study on CT acquisitions of fibulae in vivo. We studied total length, and the distal malleolar angle. Regarding intramedullary morphology, six axial study levels were defined. Each level was assigned a morphometric classification (oval, triangular, quadrangular or irregular), and a measure of the diameter of the cavity. The distance between the smaller diameter and the malleolar tip was investigated.

RESULTS

We included 50 patients for 97 fibulae. The average age was 66.5 years. The irregular morphology type was the most frequently found. The average length was 370.5 mm (SD = 18.1; CI 95% [366.9; 374.1]), the average distal malleolar angle was 163.5° (SD = 3.7; CI 95% [162.7; 164.2]). The average minimal intramedullary diameter at malleolus level was 3.2 mm (SD = 1.2; CI 95% [3.0; 3.5]), with a minimum size reaching 95.8 mm (SD = 13.8; CI 95% [93.0; 98.5]) of the malleolar tip.

CONCLUSIONS

The analysis of morphological parameters of the fibula, in particular the lateral malleolus and intramedullary morphology is necessary for the design of a morpho-adapted nail. Interpersonal variability must be taken into account by the implant industry to offer nails of suited lengths and diameters.

A multicentric study

PURPOSE

Antegrade intramedullary nailing is an alternative for humeral shaft fracture treatment. This surgical technique can be especially demanding in some fracture patterns, leading to problems like malunion and non-union. The purpose of our study is to demonstrate that the use of a nail with cerclage wires could be a safe procedure that facilitate reduction, specially in fractures with abduction of the proximal fragment.

MATERIALS AND METHODS

Fifty-six patients were included, from January 2007 to March 2016. In this cohort forty-two patients were females and eighteen males; mean age was sixty-seven (32-89). The fractures were reduced using a cerclage wire through a small lateral or anterior approach, then, antegrade intramedullary nailing was performed. Fracture healing was established by clinical and radiographic evaluation. Shoulder function was assessed using the Constant Score.

RESULTS

Fifty-three patients healed (94.6%) adequately. Two patients developed a non-union (3.5%). One patient developed an infection (1.8%). Transient radial nerve palsy was observed in two patients (3.5%). The mean Constant Score at the end of the study was 70 points (range from 34 to 98 points).

CONCLUSIONS

Surgical treatment of humeral shaft fractures with cerclage wire and intramedullary nailing is a safe technique to improve fracture reduction. The use of cerclage wires leads to better bone contact while minimizing malunions. The rate of non-union in our study is lower than the rate reported in the literature for humeral shaft fractures treated by intramedullary nailing alone.

WITHDRAWN: Challenges in the management of floating knee injuries: Results of treatment and outcomes of 224 consecutive cases in 10 years

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Injury, 50(2) (2019) 453–461, https://doi.org/https://doi.org/10.1016/j.injury.2018.12.009. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Early local microcirculation is improved after intramedullary nailing in comparison to external fixation in a porcine model with a femur fracture

INTRODUCTION

The local circulatory changes induced by intramedullary reaming are not fully understood. This study aimed to analyse the short-term local microcirculation associated with different surgical strategies in a porcine model with a mid-shaft fracture.

METHODS

German landrace pigs were subjected to a standardised femoral fracture under standard anaesthesia and intensive care monitoring. One group was subjected to intramedullary reaming and nailing (nail group), while a second group was stabilised with external fixation (fix ex group). Microcirculation [e.g. relative blood flow (flow), oxygen saturation and relative haemoglobin concentration] was measured in the vastus lateralis muscle adjacent to the fracture using an O2C (oxygen to see, LEA Medizintechnik GMBH) device at 0 (before fracture, baseline), 6 (90-min posttreatment), 24, 48 and 72 h.

RESULTS

A total of 24 male pigs were used (nail group, n = 12; fix ex group, n = 12). During the observation period, a significant increase of flow was found at 6 (P = 0.048), 48 (P = 0.023) and 72 h (P = 0.042) in comparison with baseline levels. Local oxygen delivery was significantly higher at 48 (P = 0.017) and 72 h (P = 0.021) in animals in the nail group compared to animals in the external fixation group.

CONCLUSION

This study used a standardised porcine femoral fracture model and determined a significant increase in local blood microcirculation (e.g. flow and oxygen delivery) in animals treated with intramedullary reaming compared to external fixation. These changes may be of importance for fracture healing and local and systemic inflammatory responses. Further studies in this area are justified.

[Humeral shaft fractures]

There is still no gold standard for the treatment of humeral shaft fractures. This might be attributed to the fact that several commonly used treatment methods have shown good clinical results. A bimodal age distribution of humeral shaft fractures with frequency peaks between 20 and 30 years old and above 60 years old is reported. Decision making for conservative or operative treatment depends not only on the injury pattern but is also dependent on individual patient needs. Currently available operative techniques include antegrade and retrograde interlocking medullary nailing as well as the use of longer proximal humeral nails. Plate osteosynthesis can be performed as open reduction and internal fixation (ORIF) or as minimally invasive plate osteosynthesis (MIPO). There is currently insufficient evidence for a clear superiority of either of the methods. Radial nerve palsy is the most typical complication of humeral shaft fractures but an improved outcome is not achieved by an emergency revision of the nerve.

Tibio-calcaneal fusion by retrograde intramedullary nailing in charcot neuroarthropathy

INTRODUCTION

Charcot's neuroarthropathy of ankle leads to instability, destruction of the joint with significant morbidity that may require an amputation. Aim of surgical treatment is to achieve painless stable plantigrade foot through arthrodesis. Achieving surgical arthrodesis in Charcot's neuroarthropathy has a high failure rate. We assess the outcomes of retrograde intramedullary interlocked nailing in tibio-talar arthrodesis for Charcot's neuroarthropathy.

MATERIALS AND METHODS

42 diabetic patients with a mean age of 49 year underwent ankle tibio-talar arthrodesis using retrograde nailing for Charcot's neuroarthropathy. The postoperative complications have been discussed and their management outlined. The outcomes were measured radiologically and clinically. Follow up was done after 6 weeks, 3 months, 6 months and 1 year.

RESULTS

14 patients (33.3%) achieved uneventful uncomplicated fusion. Thirty three patients had varus deformity. Nine patients had valgus deformity. Using Paired t test, it showed statistically significant improvement in the functional outcomes (AOFAS& EQ-5D-5L) over the follow up time, despite of the mild deterioration of radiological angles in the final follow up visit compared to the postoperative radiological findings.

CONCLUSION

Retrograde nailing is one of the best options for tibio-talo-calcaneal arthrodesis in the high-risk Charcot's neuroarthropathy population. It could be done through small incisions with lower soft tissue complications, its load-sharing properties allows a considerable compression across the ankle and talocalcaneal joints with early weight bearing and with satisfactory functional outcomes.

Diaphyseal long bone nonunions - types, aetiology, economics, and treatment recommendations

The intention of the current article is to review the epidemiology with related socioeconomic costs, pathophysiology, and treatment options for diaphyseal long bone delayed unions and nonunions. Diaphyseal nonunions in the tibia and in the femur are estimated to occur 4.6-8% after modern intramedullary nailing of closed fractures with an even much higher risk in open fractures. There is a high socioeconomic burden for long bone nonunions mainly driven by indirect costs, such as productivity losses due to long treatment duration. The classic classification of Weber and Cech of the 1970s is based on the underlying biological aspect of the nonunion differentiating between "vital" (hypertrophic) and "avital" (hypo-/atrophic) nonunions, and can still be considered to represent the basis for basic evaluation of nonunions. The "diamond concept" units biomechanical and biological aspects and provides the pre-requisites for successful bone healing in nonunions. For humeral diaphyseal shaft nonunions, excellent results for augmentation plating were reported. In atrophic humeral shaft nonunions, compression plating with stimulation of bone healing by bone grafting or BMPs seem to be the best option. For femoral and tibial diaphyseal shaft fractures, dynamization of the nail is an atraumatic, effective, and cheap surgical possibility to achieve bony consolidation, particularly in delayed nonunions before 24 weeks after initial surgery. In established hypertrophic nonunions in the tibia and femur, biomechanical stability should be addressed by augmentation plating or exchange nailing. Hypotrophic or atrophic nonunions require additional biological stimulation of bone healing for augmentation plating.

Surgical outcomes of intramedullary nailing for diaphyseal atypical femur fractures: is it safe to modify a nail entry in bowed femur?

INTRODUCTION

The purpose of the study was to determine the surgical outcomes of intramedullary nailing in diaphyseal atypical femoral fractures (AFFs) and to evaluate the clinical outcomes of nail entry modification technique.

MATERIALS AND METHODS

We retrospectively reviewed diaphyseal AFFs treated with IMN at nine institutions. In total, 82 patients were included. Surgical outcomes such as complication, union time, and femoral bowing were evaluated. We modified the nail entry of the straight nail from piriformis fossa to the tip of the greater trochanter in the bowed femur and compared the surgical outcomes between the original group and the modification group.

RESULTS

The average union time was 20.1 weeks, and the union rate was 89.0%. The average union time was 13.1 weeks and 21 weeks in incomplete and complete AFFs, respectively. There was no nonunion in incomplete AFFs, but 13.8% in complete AFFs. Complete AFFs had 86.2% of union rate. There were 46 cases of group 1 with original entry point and 19 cases of group 2 with modified entry. In group 2, the union rate was similar to group 1 and union time was shorter.

CONCLUSION

Changing the entry point laterally allowed the nail to be accommodated in bowed femurs, decreasing the risk of deformity and improving healing time. In severely varus femur, the lateral entry of the straight nail can be a useful technique.

Case series of patients with pathological dyaphiseal fractures from metastatic bone disease

INTRODUCTION

Fractures on pathologic bone have major impact on life quality. The appropriate treatment is not standardized, but the current literature delineates that surgery must provide adequate stabilization for the life expectancy. We aimed to review the epidemiology, treatment outcomes and survival in our department.

MATERIAL AND METHODS

The electronic database from a major referral centre was searched for patients treated for tumours and fractures by the corresponding ICM-10 codes over five years. Eighty-nine patients were identified. Eleven females and nine males, with an average age of 64 years underwent 23 operations during the selected timeframe. Six fractures were subtrochanteric, five at the femoral neck and five at the femoral diaphysis. Seventeen cases were metastatic carcinomas, out of which five mammary, three pulmonary and seven carcinomas of undetermined origin without immunohistochemistry.

RESULTS

Fourteen types of surgical intervention were osteosynthesis with intramedullary nails and six were partial hip replacements of which one had proximal femur resection and revision stem hemiarthroplasty. Four patients had single metastatic lesions which underwent resection and defect filling using PMMA cement (polymethylmethacrylate). The follow-up period ranged between two and seven years or until death. Only five patients (25%) were alive at the last follow-up. Local recurrence appeared in one patient. There was one immediate post-operative complication (dehiscent wound) and one implant failure after five years and was replaced with a larger diameter (exchange nailing).

CONCLUSION

Both hip arthroplasty and femoral nailing are safe and routine procedures that are performed with relatively technical ease and low surgical stress and few peri-operative complications for the patient. They allow for immediate mobilization and weight-bearing with moderate and rapidly decreasing pain and discomfort.

How to achieve and to maintain correct reduction?

Intramedullary nailing has become the standard for the treatment of long bones diaphyseal fractures. Modern techniques of locking have further enlarged the primary indications to more proximal and distal fractures relying upon a former correct alignment. Nevertheless, residual deformities are not rare as once the nail has left the narrow diaphyseal canal and comes into the wider metaphysis, it may follow an unwished trajectory. There is also a chance for malreduction in diapyhseal fractures. The more complex the fracture is, the more difficult its reduction, not only for the alignment of the proximal or the distal part of bone in relation to the diaphysis, but also correct rotation and length. In this paper, we analyze recommended techniques to achieve accurate bone fracture reduction, to avoid post-operative deformities combined with correct implant insertion.

A comparative study of intramedullary interlocking nailing and minimally invasive plate osteosynthesis in extra articular distal tibial fractures

BACKGROUND

Extraarticular distal tibial fractures are among the most challenging fractures encountered by an orthopedician for treatment because of its subcutaneous location, poor blood supply and decreased muscular cover anteriorly, complications such as delayed union, nonunion, wound infection, and wound dehiscence are often seen as a great challenge to the surgeon. Minimally invasive plate osteosynthesis (MIPO) and intramedullary interlocking nail (IMLN) are two well-accepted and effective methods, but each has been historically related to complications. This study compares clinical and radiological outcome in extraarticular distal tibia fractures treated by intramedullary interlocking nail (IMLN) and minimally invasive plate osteosynthesis (MIPO).

MATERIALS AND METHODS

42 patients included in this study, 21 underwent IMLN and 21 were treated with MIPO who met the inclusion criteria and operated between June 2014 and May 2015. Patients were followed up for clinical and radiological evaluation.

RESULTS

In IMLN group, average union time was 18.26 weeks compared to 21.70 weeks in plating group which was significant (P < 0.0001). Average time required for partial and full weight bearing in the nailing group was 4.95 weeks and 10.09 weeks respectively which was significantly less (P < 0.0001) as compared to 6.90 weeks and 13.38 weeks in the plating group. Lesser complications in terms of implant irritation, ankle stiffness, and infection, were seen in interlocking group as compared to plating group. Average functional outcome according to American Orthopedic Foot and Ankle Society score was measured which came out to be 96.67.

CONCLUSION

IMLN group was associated with lesser duration of surgery, earlier weight bearing and union rate, lesser incidence of infection and implant irritation which makes it a preferable choice for fixation of extra-articular distal tibial fractures. However, larger randomized controlled trials are required for confirming the results.

Humeral shaft non-union after intramedullary nailing

BACKGROUND

The humerus shaft is one of the sites with the largest probability of developing pseudoarthrosis after fracture. We present the results of nine patients with atrophic pseudoarthrosis of humeral shaft treated with angular stability plate associated with allograft and platelet-rich plasma (PRP), after a first treatment with intramedullary nail to correct the fracture.

MATERIAL AND METHODS

From January 2012 to December 2014, nine patients were treated for atrophic pseudoarthrosis (PSA) of humeral shaft treated previously using intramedullary nail; seven humeral diaphysis fractures were located in the middle-proximal third and two in the middle third. In one case, a reverse shoulder prosthesis implant was associated to treat a co-existent rotator cuff massive lesion. The mean time between injury and treatment of non-union was 32 weeks (min 16-max 180); all patients were evaluated with Constant, DASH and UCLA score.

RESULTS

At the final follow-up (23.7 months), the mean Dash score was 22.25 pt, the Constant score was 64 pt, and the UCLA score value was 27 pt. The average pain value was 2 for the arm interested and 0 into PSA focus. Radiographic healing was obtained at 7 months.

CONCLUSIONS

The humeral shaft non-union is an invalidating problem which affects the daily living. Our treatment with plate, cortical bone graft, and PRP can build a high-stability structure that can help healing and graft integration.

A Newly Designed Intramedullary Nail for the Treatment of Diaphyseal Forearm Fractures in Adults

BACKGROUND

The treatment of diaphyseal forearm fractures using open reduction and plate fixation is generally accepted as the best choice in many studies. However, periosteal stripping, haematoma evacuation may result in delayed union, nonunion and infection. Refracture after plate removal is another concern. To overcome these problems intramedullary nails (IM) with different designs have been used with various outcomes. However previous IM nails have some shortcomings such is rotational instability and interlocking difficulties. We evaluated the results of newly designed IM nail in the treatment of diaphyseal forearm fractures in adults.

MATERIALS AND METHODS

32 patients who had been treated with the interlocking IM nail for forearm fractures between 2011 and 2014 were included in this study. There were 23 males and 9 females with mean age of 36 years (range 18-68 years). 22 patients (68.8%) had both bone fractures. Nine patients (28.1%) had open fractures. The remaining ten patients (31.2%) had radius or ulna fractures. Grace and Eversmann rating system was used to assess functional evaluation. Patient reported outcomes were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores.

RESULTS

Union was achieved in all patients. The mean followup was 17 months (range 13 - 28 months). According to the Grace-Eversmann criteria, 27 patients (87.5%) had excellent or good results. The mean DASH score was 14 (range 5-36). Overall complication rate was 12.5%. Superficial infection was encountered in two patients. One patient had delayed union, however fracture healed without any additional surgical procedure. One patient who had open grade 3A, comminuted proximal third radius fracture developed radioulnar synostosis.

CONCLUSIONS

The new design IM interlocking forearm nail provides satisfactory functional and radiological outcomes in the treatment of adult diaphyseal forearm fractures.

Does it matter?

BACKGROUND

Intramedullary nailing for fractures of middle third clavicle has become increasingly popular. Though open nailing has been widely described, closed nailing finds less mention.

OBJECTIVES

In this study we compared closed nailing with open nailing in fractures of middle third of clavicle to assess if the former holds any advantage.

MATERIAL AND METHODS

34 patients with closed nailing were compared to 31 patients with open nailing in terms of operative time, length of incision, pain, time to union and functional outcome.

RESULTS

Only operative time and length of incision were significantly more in open group than in closed group.

DISCUSSION

We believe that closed reduction can be attempted in all patients undergoing nailing for middle third clavicle fracture but surgeon should have a low threshold to open the fracture if closed reduction fails as functional outcome and time to union remains unaffected.

Challenge to treat hypertrophic nonunion of the femoral shaft: the Poller screw augmentation technique

The management of a femoral nonunion after intramedullary nailing is challenging. Exchange nailing or plate augmentation has been used to treat hypertrophic nonunions previously. The Poller screw augmentation technique is a simple procedure that can be performed in the outpatient surgery. In this study, we highlight the method of hypertrophic nonunion management according to the specific indication including our Poller screw augmentation technique.

Provisional pin fixation can maintain reduction in A3 intertrochanteric fractures

A3 intertrochanteric fracture has a higher incidence of intraoperative re-displacement than A1 and 2. The authors have also experienced difficulty with maintenance of reduction in A3 intertrochanteric fractures, as the technique depends on manual effort and can fail easily during the procedure. It induced us to develop this surgical technique to ease the surgical procedure and improve clinical outcomes. This paper introduces a modified provisional guide pin fixation technique applicable to even AO/OTA A3 intertrochanteric fractures, and presents preliminary results of 11 patients who were treated by provisional pin fixation-assisted nailing in A3 intertrochanteric fractures. Using this technique, we have reduced the chances of intraoperative reduction loss and achieved favorable clinical outcomes.

Comparison of retrograde nailing and minimally invasive plating for treatment of periprosthetic supracondylar femur fractures (OTA 33-A) above total knee arthroplasty

INTRODUCTION

Retrograde intramedullary (IM) nailing and minimally invasive plate osteosynthesis (MIPO) using locking plate are typically considered the gold standards of treatment for periprosthetic supracondylar femoral fractures above total knee arthroplasty (TKA).

METHODS

Forty-one consecutive patients treated with either retrograde nailing (nail group, n = 20) or minimally invasive plating (plate group, n = 21) for periprosthetic supracondylar femoral fractures between March 2003 and January 2014 were retrospectively reviewed. Clinical functions [arc range of motion and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score] and bony outcomes (bony union and malunion) were evaluated.

RESULTS

There was no statistical difference between the nail and plate groups in age (p = 0.665), one-year postoperative arc range of motion (p = 0.642), preoperative WOMAC score (p = 0.076), postoperative one-year WOMAC score (p = 0.135), and union time (p = 0.081). The mean union time of the nail group and the plate group was 4.3 months (range 3-12 months) and 3.6 months (range 3-5 months), respectively. There were three cases of malalignment in the nail group, whereas there was one case of malalignment in the plate group (p = 0.343). One case of nailing using a short nail demonstrated nail breakage.

CONCLUSIONS

Although retrograde nailing was found to have a slightly higher rate of malunion compared to minimally invasive plating, there was no statistically significant difference between both treatment options in terms of clinical outcomes. Regardless of which implant is used, the proper application is essential in management of periprosthetic supracondylar femoral fractures above TKA.

Treatment Outcome of Intramedullary Fixation with a Locked Rigid Nail in Humeral Shaft Fractures

BACKGROUND

The aim of this study was to determine the treatment outcome of humeral shaft fractures with a locked rigid intramedullary nail in patients indicated for surgical treatment.

METHODS

In this descriptive-cross sectional study, all patients were followed up for one, six, and 18 months post operatively. The Short Form Questionnaire (SF-36) and Constant Shoulder Score were applied.

RESULTS

Of 78 included patients (mean age: 35), one patient had a soft tissue infection, one had secondary radial nerve palsy, eight had non-union, one had elbow limited range of motion in extension, and three patients had decreased shoulder range of motion. The Constant Shoulder Score and Short Form Questionnaire Score (SF-36) increased in all patients, although aged women showed lower improvement.

CONCLUSION

Intramedullary nail fixation in the humeral shaft fracture may be associated with high rates of non-union.

Cost of external fixation vs external fixation then nailing in bone infection

AIM: To study the cost benefit of external fixation vs external fixation then nailing in treatment of bone infection by segment transfer.

METHODS: Out of 71 patients with infected nonunion tibia treated between 2003 and 2006, 50 patients fitted the inclusion criteria (26 patients were treated by external fixation only, and 24 patients were treated by external fixation early removal after segment transfer and replacement by internal fixation). Cost of inpatient treatment, total cost of inpatient and outpatient treatment till full healing, and the weeks of absence from school or work were calculated and compared between both groups.

RESULTS: The cost of hospital stay and surgery in the group of external fixation only was 22.6 ± 3.3 while the cost of hospital stay and surgery in the group of early external fixation removal and replacement by intramedullary nail was 26.0 ± 3.2. The difference was statistically significant regarding the cost of hospital stay and surgery in favor of the group of external fixation only. The total cost of medical care (surgery, hospital stay, treatment outside the hospital including medications, dressing, physical therapy, outpatient laboratory work, etc.) in group of external fixation only was 63.3 ± 15.1, and total absence from work was 38.6 ± 6.6 wk. While the group of early removal of external fixation and replacement by IM nail, total cost of medical care was 38.3 ± 6.4 and total absence from work or school was 22.7 ± 4.1. The difference was statistically significant regarding the total cost and absence from work in favor of the group of early removal and replacement by IM nail.

CONCLUSION: Early removal of external fixation and replacement by intramedullary nail in treatment of infected nonunion showed more cost effectiveness. Orthopaedic society needs to show the cost effectiveness of different procedures to the community, insurance, and health authorities.

Results of angular-stable locked intramedullary nails in the treatment of distal tibia fractures

INTRODUCTION

Intramedullary nailing in distal tibial fracture is controversial because of a lack of stability. The present study sought to assess radiological and clinical results for a new "angular-stable" locking system in difficult indications for intramedullary nailing.

MATERIAL AND METHOD

A prospective study recruited 41 patients (41 tibias) with distal tibial fracture consecutively managed using angular-stable locked intramedullary nails. Radiologic assessment comprised AP and lateral lower-limb views, taken postoperatively and through to last follow-up. The mean distance was measured between fracture and joint line. Fusion, with or without malunion, primary reduction defect, non-union and secondary displacement were recorded, as were all complications.

RESULTS

Mean follow-up was 18 ± 5 months; 3 patients were lost to follow-up. Mean fracture distance from the joint line was 63 ± 25 mm. Fusion was achieved within 3 months in 29 cases (76%); delayed fusion in 7 patients (18%) required secondary dynamization at a mean 3 months, with favorable evolution. Revision surgery was required in 2 cases: 1 for secondary displacement exceeding 10°, and 1 for non-union at 7 months. Other complications mainly comprised 4 malunions of less than 10° due to primary reduction defect.

CONCLUSION

Angular-stable locked lower-limb intramedullary nailing provided a very satisfactory fusion rate, with few complications. It is, however, a demanding procedure, especially as regards fracture reduction and nail positioning in the distal fragment.

PROSPECTIVE COHORT STUDY

level IV.