Clinical Union Research Articles

Bridge plating for simple tibial fractures treated by minimally invasive plate osteosynthesis

ABSTRACT This study aimed to evaluate the effectiveness of bridge plating of simple tibial fractures in dogs by minimally invasive plate osteosynthesis (MIPO). Medical and radiographic records of twenty-nine dogs with simple tibial fractures that underwent bridge fixation by MIPO were retrospectively evaluated. The clinical outcome was classified considering the presence of lameness at the end of the treatment. The tibial mechanical joint angles were measured and compared with the values described in the literature. Additionally, fragment apposition and implant disposition were evaluated. Based on the modified Radiographic Union Scale for Tibial fractures, the moment of clinical union was determined. Clinically, at the end of treatment, only one patient presented lameness at a trot. While there was no significant difference between the bone alignment in the frontal plane values and the values described in the literature (P>0.05), the caudal proximal tibial angle was significantly higher (P=0.001). The median fragment apposition was considered acceptable. The average bridge plate ratio, plate working length, and plate screw density were 0.8, 0.57, and 0.48, respectively. The median time to clinical union was 30 days. Bridge plating in simple tibial fractures resulted in fast healing and low complication rates.

Outcomes of Tibiotalocalcaneal Arthrodesis with a Femoral Nail.

Retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis (TTCA) is used for severe hindfoot deformities, end-stage arthritis, and limb salvage. The procedure is technically demanding, with complications such as infection, hardware failure, nonunion, osteomyelitis, and possible limb loss or death. This study reports the outcomes and complications of patients undergoing TTCA with a femoral nail, which is widely available and offers an extensive range of lengths and diameters. We performed a retrospective review of 104 patients who underwent 109 TTCAs using a femoral nail as the primary procedure (January 2006 through December 2016). Demographic data, risk factors, and outcomes were evaluated. At final follow-up, the overall clinical union rate was 89 of 109 (81.7%). Diabetes mellitus was negatively associated with limb salvage (P = .03), and peripheral neuropathy (P = .02) and Charcot's neuroarthropathy (P = .03) were negatively associated with clinical union. Only four patients (3.8%) underwent proximal amputation, at an average of 6.1 months, and 11 patients (10.6%) died, at a mean of 38.0 months. The most common complication was ulceration in 27 of 109 limbs (24.8%), followed by infection in 25 (22.9%). Twenty-three patients (22.1%) underwent revision procedures, at a mean of 9.4 months. Thirteen of these 23 patients (56.5%) had antibiotic cement rod spacers/rods for deep infection-related complications. Use of a femoral nail has been shown to provide similar outcomes and limb salvage rates compared with other methods of TTCA reported for similar indications in the literature.

Interprosthetic femoral fractures managed with modern distal femoral locking plates: 10 years’ experience at a UK major trauma centre

IntroductionInterprosthetic femoral fractures (IFF) are rare but increasing with an ageing population. Operative management is challenging and there is currently a paucity of outcome data in literature. The purpose of this study was to evaluate outcomes of IFFs managed with modern distal femoral locking plates, in a larger sample size than previously published. MethodThis retrospective study reviewed 49 closed IFFs in 48 patients at a major trauma center from 2009 to 2019 occurring between previous total hip arthroplasty (n=38), hemi hip arthroplasty (n=3), dynamic hip screw (n=6) or cephalomedullary nail (n=2) and total knee arthroplasty. They were managed with Minimally Invasive Plate Osteosynthesis (MIPO) employing modern biological fixation techniques and stabilised with VA-LCP Condylar (Synthes; n=28) or Peri-Loc (S&N; n=21) plate. Clinical and radiographic outcomes were measured. ResultsThe majority of fractures were in female patients (80%), who were elderly (average 83 years), and comorbid (55% ASA grade 3 or 4). Most fractures were Pires type IIA and OTA/AO type 33A. Average plate spanning femur was 16 holes, with average working length of 6 holes. 86% had unrestricted weight bearing immediately post operatively. 31 fractures reached radiological (n=25) or clinical (n=6) union. 13 patients died with 2 lost to follow up. There were 3 non-unions, with implant failure occurring before 4 months in all 3. We present a union rate of 91% (n=31/34). ConclusionIFFs are occurring with increasing frequency in a frail elderly population. In patients with IFFs, MIPO and biological fixation techniques using modern distal femoral locking plates can achieve high rate of union when combined with immediate unrestricted weight bearing postoperatively.

Posterolateral Plating of Distal Tibia Fractures: Extending the Use of a Familiar Approach.

Distal tibia fractures present challenges in surgical management and when nailing is not an option, plate osteosynthesis is performed. This is usually done with a minimally invasive approach to reduce the risk of wound complications in an already fragile soft-tissue envelope. We propose that a posterolateral open approach can lead to stable fixation construct and comes with advantages of approaching fibula fractures via same approach and has a thicker soft tissue envelope over the fixation. We report a series of distal tibia fractures with posterolateral plate fixation and present the outcomes. This is a retrospective review conducted at a single institution, where 13 patients underwent posterolateral approach for distal tibia fracture fixation. Where required, medial plating and fibular fixation was additionally performed. Patients were followed-up with primary endpoint of successful clinical and radiological union or complications required re-intervention. Operative and long-term clinical outcomes were recorded. Long term follow-up was available for 12 patients. There was 1 non-union requiring revision (8.3%). For the other patients, clinical union occurred by 14.5weeks and radiological union by 20weeks on average. There was no malunion and 2 patients (16.6%) underwent removal of implants for symptoms of hardware irritation. We found that outcomes in our cohort demonstrate posterolateral plating is safe as a primary or adjunctive method of fixation, and does not compromise other outcomes when compared with traditional fixation methods.

Comparative study of distal femoral locking compression plate and tens nail versus lateral distal femur plate in management of distal femur fracture cases

Background: The fracture of distal femur are often unstable and comminuted and as difficult to treat. The incidence of complications in these fracture are relatively high .The purpose of our study was aimed to compare functional outcome between both column fixations by using distal femoral locking compression pate on lateral side and then using TENS nail on medial side to obtain support of medial column versus lateral distal femoral plate.Methods: We have included 80 patients with distal femur fracture with intercondylar extension in our study. We have treated 40 patients with distal femoral locking compression plate and support of medial wall with TENS nail and 40 patients with distal femoral locking compression plate. There were sixty six males and fourteen females. The average age of the patients was 39.08 ± 11.95 years. All the patients were operated between 3 to 9 days. All patients were followed up at 2th, 6th, 10th weeks, 3 month and 6 month regularly and evaluated for fracture healing, Clinical union was defined as a painless fracture site during full weight bearing. Radiological union was defined as bridging trabeculation across the fracture site on three of four cortices. The final outcome was assessed according to schatzker and Lambert scoring system.Results: The result was excellent in twelve, good in fifteen, fair in ten and poor in one in DFLCP with TENS nail group according to schatzker and Lambert scoring system. The result was excellent in eight, good in twelve, fair in twelve and poor in five in DFLCP group according to schatzker and Lambert scoring system. The average time to Union was 17.7 weeks in DFLCP with TENS nail group and 19.9 weeks in DFLCP group. Complications include superficial wound infection in three patients, secondary osteoarthritis in 17 patients and varus angulation in three patients in DFLCP with TENS nail group. In DFLCP group varus angulation was in eleven patients.Conclusions: The use of TENS nail for medial femoral defect along with distal femoral locking compression plate may eliminate the need of plate on medial side. The varus angulation that occurs with defect is decreased and additional long incision and operative time is avoided.

Clinical application of the small I‐Loc interlocking nail in 30 feline fractures: A prospective study

To describe medium-term functional outcome after nail osteosynthesis in feline traumatology and report clinically relevant recommendations for I-Loc angle-stable interlocking nail use in cats. Prospective clinical study. Client-owned cats (n = 29). Consecutive cases with femoral, tibial, or humeral fractures were included. Outcome measures included fracture and surgical procedure description, limb alignment, nail size vs body weight (BW), percentage of nail medullary canal (MC) fill, time to limb function at clinical union (CU), and complications. Descriptive statistics were reported and compared with historical data. Bone distribution was 53.3% femora, 30% tibiae, and 16.7% humeri. There were six epimetaphyseal and 24 diaphyseal fractures. Overall, 67% of fractures were comminuted. Open reduction and minimally invasive techniques were used in 73% and 27% of cases, respectively. Seventeen I-Loc 3 (cat mean BW 4.4 ± 2.2 kg) and 13 I-Loc 4 (cat mean BW 5.2 ± 1.2 kg) nails were placed with mean MC fill of ≤50%. Average time to CU was 7.2 weeks. At CU, lameness had resolved or was mild in every cat, and all cats ultimately regained full limb function. No major complications were encountered. Because of improved CU times, excellent functional outcomes, and low complication rate, our results provide evidence that I-Loc nails are safe and effective for feline traumatology. The I-Loc may be advantageous for fixation of epimetaphyseal fractures. Because of feline bone specific dimensional constraints, I-Loc 3 is likely appropriate for all feline humeri and most tibiae, while I-Loc 4 is well sized for feline femora.

Two-stage bone-and-strut technique in the treatment of septic non-unions in the upper limb.

Aim To report the results of a two-stage reconstruction of septic non-unions of the upper limb using the bone-and-strut technique with a follow-up of more than two years. Methods A total of 19 patients (12 males and seven females; age 27 to 85 years) were included in this cohort study. The evaluation endpoint was set at 24 months. Radiographic union, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores, pain and return to work were assessed. All patients were treated with debridement and antibiotic therapy. At a second stage, the nonunion focus was filled with a cancellous bone allograft. Stability was provided using a locking plate and a bone strut. Results After 24 months, the QuickDASH scores improved from a median of 28 (interquartile range, 13 - 35 points), to a median of 78 (interquartile range, 70 - 89 points). Mean pain scores improved from 8.1 (range, 0.3-10) to 0.6 (range 0-2). Radiographic and clinical union was seen in all patients. The majority of patients returned to work or previous activities when retired. A new neurological deficit, recurrence of infection, or other surgery-related adverse events were not observed. Conclusion The two-stage bone-and-strut technique is a safe and effective technique in the treatment of septic non-unions of the upper limb. The union rate is high, the complication rate is acceptable and return return-to-work is high. Recurrence of infectious sequelae during a follow-up period of at least two years was not seen. The patient-reported outcomes increased significantly.

MANAGEMENT OF DISTAL FEMUR FRACTURES IN ADULT WITH LOCKING COMPRESSION PLATE

Objective: To evaluate the clinical outcomes and radiological union of distal third femur fractures by using distal femur locking plate, in Zagazig university hospitals and KafrSaad emergency hospital. Design: Clinical trial. Methods: Data collected for the study was from the patients admitted in orthopedic department in Zagazig university hospitals and KafrSaad emergency hospital, with distal femur fracture AO 33,during the period of August 2019 to July 2020 and treated with open reduction and internal fixation with distal femur locking compression plate with 4.5 system. All patients were followed up for an average of 6 months. Outcomes were assessed by Neers score. Results: Outof 12 patients (4 were females&8were males), mean age was 45.6 years (20 to 70 years). 10 cases wereduo to high energy trauma and 2 cases wereduo to low high energy trauma.5 out of total 12 cases had open fractures and rest 7 cases had closed fractures.Out of total 12 cases, five cases were extra-articular and rest 7 cases were intra-articular. Out of 12 fractures treated, 8 fractures showed radiological signs of union within 12-16 weeks,3 fractures showed radiological signs of union within 20 weeks and one fracture showed radiological signs of union within 24 weeks.1 patient got superficial infection and no implantfailure, mean range of motion of all patients was 113°. Conclusion:ORIF of distal femur fractures with locking compression plate provides good angular stability, restoration of limb alignment, length, rotation and give a good purchase in osteoporotic patientswith minimal complications. Best results are optioned when standard protocol of locking plate fixation is followed with good soft tissue care, early knee bending exercises and physiotherapy.

A Novel Surgical Method for Treating Symptomatic Incomplete Atypical Femoral Fracture using Percutaneous Elastic Intramedullary Nailing.

Purpose:To introduce the principles and procedure of percutaneous elastic intramedullary nailing (PEIN) as a treatment for symptomatic incomplete atypical femoral fracture (SIAFF).Methods:From October 2014 to April 2019, 6 cases of SIAFF were treated with PEIN. Two pre-bent 4-mm stainless-steel nails were used to apply compressive force to the fracture site. The antegrade method was used for proximal fractures and the retrograde method for middle and distal femoral fractures. The femoral bowing angle in the coronal and sagittal planes, and the time required for callus formation and union, were evaluated on plain radiographs in both planes. Thigh pain, tenderness, and complications were also assessed.Results:The mean operating time was 65.00 ± 22.64 min. No case progressed to complete atypical fracture. In one case, fracture occurred around the point of nail entry after the patient fell from a chair on postoperative day 7. The incomplete fracture lines were united in 5 cases, after excluding one case with a complication. The time taken to confirm endocortical callus formation, fracture line disappearance, and clinical union was 2.11 ± 0.53, 6.45 ± 4.10, and 6.45 ± 3.65 months, respectively.Conclusions:PEIN is a quick, simple but effective treatment for SIAFF that considers the fracture mechanism and is applicable to cases with severe femoral bowing.Level of evidence:Level IV, case series.

Evaluation of diaphyseal femoral fractures in children treated with tens nailing: A clinical study

Femur fracture is very common fracture in children. Femur shaft fracture around 2% pediatrics age group fracture. Various methods are used to treatment in femur fracture. Like hip Spica, plating, nailing with tens or Enders nailing. Enders and tens are commonly used methods. Purpose of study: The know of outcome of elastic tens nailing in pediatrics shaft fracture. Material and Method: We study’s 24 children’s of fracture shaft of femur between age group 5 to 14. Result: The minimum fellow up to 8 month. The average time taken to full weight bearing and clinical union is 6 week to 8 week. In 3 cases there is superficial infection present in 2nd week of post-surgery. Which is cure by antibiotics and wound washing. No case of nonunion, out of 24 cases 12 cases have limb length discrepancy. 6 cases had lighting 6 cases had shorting. On the Flynn criteria 22 cases have excellent result 2 have satisfactory result. No cases show any unsatisfactory results. Conclusion: Cases which treated by tens elastic nailing achieved primary healing. The advantage of treating patient with enders nail had early weight bearing, reduced hospital stay, less bedridden and early to start to study. Overall tens elastic nailing is have many benefits either then conservation treatment.

The surgical management of metastatic lesions of the femur

ABSTRACT BACKGROUND: Malignant tumours commonly metastasise to bone. When this occurs in the femur, surgical intervention is required to reduce pain and restore mobility post fracture, or as a prophylactic measure when fracture is anticipated. This is typically in the form of replacement with hemi- or total arthroplasty or stabilisation with an intramedullary device. The indications for one modality over the other are debatable and the reported outcomes and complications are varied. The purpose of this study is to assess the management algorithm for bony metastasis of the femur at a tertiary bone tumour unit, and the outcomes of the surgical strategies employed METHODS: A retrospective cohort study was performed of all patients presenting to our institution with femoral metastasis, both with and without pathological fracture, who were managed surgically from April 2016 to February 2020. Fractures of the femoral neck were managed with cemented arthroplasty. All other fractures were managed with intramedullary nailing, as were all lesions requiring prophylactic stabilisation. Data was recorded regarding demographics, primary pathology, location of lesion, type of surgery, and implant used. The incidence of complications including radiological failure of fixation, infection, thromboembolic phenomena, re-operation and mortality were recorded RESULTS: Eighty-five femurs in 77 patients were included (mean age 61 years, range 20-90). Lesions were located in the femoral neck (19/85, 22%), intertrochanteric (20/85, 24%), subtrochanteric (40/85, 47%), diaphyseal (2/85, 2%) and metaphyseal/per-condylar (4/85, 5%) regions of the femur. A total of 64/85 (753%) procedures were performed for fractures and 21/85 (25%) prophylactically. Eighteen of the 85 (21%) underwent long-stemmed cemented bipolar hemiarthroplasty, 1/85 (1%) long-stemmed cemented total hip replacement (THR), 62/85 (73%) cephalomedullary nailing, and 4/85 (5%) retrograde femoral intramedullary nailing. Mean follow-up was eight months (range 1-36). There were no dislocations or periprosthetic fractures in the arthroplasty group. One failure (1/66, 2%) of fixation occurred in the intramedullary nailing group. Six deaths occurred in the arthroplasty group (6/64, 9%) and 24 in the nailing group (24/66, 36%) during the study period. Four patients suffered from thromboembolic phenomena (4/77, 5%). Of the 13 patients who sustained a pathological fracture and were managed with intramedullary nailing and followed up for at least one year, all had achieved clinical and radiological union CONCLUSION: Femoral metastasis can be appropriately managed with intramedullary nailing, both prophylac-tically and in the event of fracture, with a low rate of implant failure and an expectation that healing will occur once stabilised. Intracapsular fractures can be managed with long-stemmed cemented arthroplasty with a low risk of subsequent fracture or dislocation Level of evidence: Level 4 Keywords: bone metastasis, femur, pathological fracture

Effect of Teriparatide in Fracture Healing in Lower Limbs- An Interventional Study

Introduction: Many of the trauma patients presenting to the orthopaedic departments suffer from lower limb fractures. This often leads to prolonged period of morbidity and absence from work. Fracture healing can be delayed in elderly patients, postmenopausal women and in communited fractures. Teriparatide (TPH) given subcutaneously for 6 to 9 months, in such cases, may promote clinical and radiological union of bone. Aim: To know the effect of TPH in improving clinical and radiological union and also to evaluate early weight bearing, improvement in pain and functional outcome. Materials and Methods: In this prospective interventional study, a total of 125 patients were initially enrolled for the study and then after meeting inclusion criteria total 104 patients were selected for the study. They were allocated into two groups by randomisation by 1:1 method-group A was test group of 52 cases in which subcutaneous injection TPH 20 mcg daily (for six months) was given along with standard dosage of calcium and vitamin D; while in 52 cases in group B (control group) only calcium and vitamin D were given. Injection TPH was started within 10 days of fracture and given for six months. No placebo injection was given in control group. Time to weight bearing, time to clinical and radiological union and pain by Visual Analogue Score (VAS) were noted at regular follow-up at one month, three months, six months and 12 months and were compared in both the groups. Functional outcome by Disabilities of the Arm, Shoulder and Hand (DASH) score was noted as an additional tool, as DASH score questionnaire shows many activities of daily living that require mobility and stability of lower limb too. Adverse reactions were noted and compared within test and control groups. The collected data were analysed using International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) version 22.0 software and Mann-Whitney U test was used to calculate p-value. Results: Average time period for full weight bearing with or without support for test group A was 11±2.7 weeks and 16±1.8 weeks in control group B (p-0.001). Average time to clinical union in test group was 12±1.9 weeks and in control group 16±2.2 weeks (p-0.001). Average time to radiological union was 13±1.4 weeks in test group while 22±2.2 weeks in control group (p-0.001). Pain score by VAS and functional outcome by DASH were improved in test group (p-0.001). There was no difference in adverse reactions in both the groups (p>0.05). Conclusion: Regular intake of TPH 20 mcg subcutaneous daily for six months can reduce time to clinical and radiological fracture union, promote early weight bearing and provide better pain control. Hence, better functional outcome and prefracture ambulatory status can be achieved with no significant adverse events.

Nonunion Rates in Hind- and Midfoot Arthrodesis in Current, Ex-, and Nonsmokers.

Nonunion rates in hind or midfoot arthrodesis have been reported as high as 41%. The most notable and readily modifiable risk factor that has been identified is smoking. In 2018, 14.4% of the UK population were active smokers. We examined the effect of smoking status on union rates for a large cohort of patients undergoing hind- or midfoot arthrodesis. In total, 381 consecutive primary joint arthrodeses were identified from a single surgeon's logbook (analysis performed on a per joint basis, with a triple fusion reported as 3 separate joints). Patients were divided based on self-reported smoking status. Primary outcome was clinical union. Delayed union, infection, and the need for ultrasound bone stimulation were secondary outcomes. Smoking prevalence was 14.0%, and 32.2% were ex-smokers. Groups were comparable for sex, diabetes, and body mass index. Smokers were younger and had fewer comorbidities. Nonunion rates were higher in smokers (relative risk, 5.81; 95% CI, 2.54-13.29; P < .001) with no statistically significant difference between ex-smokers and nonsmokers. Smokers had higher rates of infection (P = .05) and bone stimulator use (P < .001). Among smokers, there was a trend toward slower union with heavier smoking (P = .004). This large retrospective cohort study confirmed previous evidence that smoking has a considerable negative effect on union in arthrodesis. The 5.81 relative risk in a modifiable risk factor is extremely high. Arthrodesis surgery should be undertaken with extreme caution in smokers. Our study shows that after cessation of smoking, the risk returns to normal, but we were unable to quantify the time frame. Level III, retrospective cohort study.

Titanium elastic nails system &amp;#40;TENS&amp;#41; fixation in midshaft clavicular fractures – A prospective study

Introduction: The clavicle is most frequently and easily fractured bone, due to direct blow or fall on the outstretched hand. With changing trends in treatment of midshaft clavicle fractures, plating was one of the standard procedure remains for fixation. Recent attracting alternative new technique of fixation is the titanium elastic nailing system (TENS). Due to lacking of prospective studies, the present study was undertaken to assess effectiveness of minimally invasive method TENS for the treatment of midshaft clavicle fracture. Materials and Methods: The study population included 30 patients exclusively with fracture of midshaft clavicle on plain radiographs from January 2014 to June 2015 at a tertiary care centre. Most of cases were operated within 24-48 hours after trauma. Intra operatively, image intensifier was used for monitoring the manipulations and maneuvering of the nails for closed reductions of the fractures. Patients were followed for 6 months postoperatively and then titanium nails were removed. Result: Average age of the study population was 35.8 ± 10 yrs. Most cases were operated within 24-48 hours after trauma. In 24 cases, closed reductions and nailing were done, while in 6 cases, open reductions and nailing were done. Constant score was used to assess the clinical outcome of our patients after union of the fracture. Clinical union was achieved in 3-5 weeks, while radiographic union was achieved in 6-8 weeks. There was no post-operative infection in this study. Conclusion: Operative interventions with TENS showed better results in regards to early functional recovery. The specific advantages of TENS over plating are that it is minimally invasive, needs lesser operative time, and early mobilization. Keywords: Clavicle fracture, Titanium Elastic Nailing (TENS), Closed reduction, Open reduction.

Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty: Contemporary Outcomes of 612 Hips.

Extended trochanteric osteotomies (ETOs) provide wide femoral and acetabular exposure, give direct access to the femoral medullary canal, and facilitate implant removal and new implant placement during selected revision total hip arthroplasties (THAs). Previous studies are limited by modest patient numbers and limited length of follow-up. The goals of the current study were to assess the union rate, complications, and outcomes of contemporary ETOs performed during revision THAs. From 2003 to 2013, 612 ETOs were performed during revision THAs at 1 institution using 2 techniques: Paprosky (laterally based osteotomy; n = 367) and Wagner (anteriorly based osteotomy; n = 245). The indications for the revision procedures were aseptic loosening (65%), periprosthetic joint infection (18%), periprosthetic fracture (6%), femoral implant fracture (5%), and other (6%). The mean patient age was 69 years, and 57% of the patients were male. The mean number of previous THAs was 1.6. The median duration of follow-up was 5 years (range, 2 to 13 years). The mean Harris hip scores increased from 57 preoperatively to 77 at the latest follow-up (p < 0.001). Radiographic and clinical union was achieved in 98% of the patients at a mean of 6 months (range, 1 to 24 months). The mean migration of the proximal trochanteric osteotomy fragment prior to union was 3 mm (range, 0 to 29 mm). ETO fragment migration of >1 cm occurred in 7% (37) of the 501 hips that had radiographic analysis. Nine hips (2%) had nonunion of the ETO. Intraoperative fracture of the ETO diaphyseal fragment occurred in 22 hips (4%), postoperative fracture of the ETO diaphyseal fragment occurred in 3 hips (0.5%), and postoperative fracture of the greater trochanter occurred in 41 hips (7%). Survivorship at 10 years free of revision for aseptic femoral loosening, free of femoral or acetabular component removal or revision for any reason, and free of reoperation for any reason was 97%, 91%, and 82%, respectively. This large series of ETOs shows that the union rate is high and clinically important trochanteric migration is infrequent. The most common complications are fracture of the osteotomy fragment intraoperatively or postoperatively. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Single Antegrade Intramedullary Kirschner Wire Fixation For Transverse Metacarpal Shaft Fractures: A Retrospective Review

Introduction: Fractures of the metacarpals are frequently encountered. Transverse metacarpal shaft fractures are inherently unstable and amenable to surgical intervention. Few studies have evaluated outcomes of patients with a singular transverse metacarpal shaft fracture surgically corrected with an antegrade intramedullary Kirschner (K) wire. We present our series of patients and their outcomes performed by a single surgeon. Materials and Methods: A retrospective chart review of cases at our institution was performed on transverse metacarpal fracture treated with an intramedullary K-wire. Fifteen patients met the inclusion criteria. Data extracted included metacarpal involved, laterality, sex, age, if removal of hardware was performed, time from initial injury to surgery, tourniquet time, complications, range of motion, clinical outcome, among others. Results: All fractures occurred about the right hand with 7 involving the small finger metacarpal, 4 involving the index, 3 involving the ring, and 1 involving the middle. The average patient age was 25 years (range: 18 to 58 y). The average tourniquet time was 16 minutes (range: 10 to 20 min). There were no intraoperative complications and 1 patient had hardware removed at 8 weeks due to proximal pin site pain. All patients achieved clinical union with a return of full function. Discussion: Single antegrade intramedullary K-wire fixation is a simple, reliable, and potentially cost-effective treatment option for transverse metacarpal shaft fractures. Further research is needed to determine long-term outcomes and formal cost analysis. Our series indicate this technique can be safely utilized, with a low risk of complications and good clinical outcomes. Level of Evidence: Level IV—therapeutic.

Reliability and Usefulness of Radiographic Union Score (RUS) for Fracture Healing Assessment in Subtrochanteric Femoral Fractures

Background: The fracture healing assessment in subtrochanteric femoral fracture (SFF) is essential due to a high rate of implant failure and non-union. It requires an effective diagnostic tool for determining fracture union status. However, significant disagreement exists among clinicians for SFF union diagnosis, and no standardized method is available. Previous studies showed that radiographic union score (RUS) is reliable and highly correlated with fracture healing status. Objective: To evaluate the reliability and diagnostic accuracy of the RUS method for assessing the fracture healing status in the treatment of SFFs. Materials and Methods: The present study was a retrospective review study conducted on 44 SFFs. A panel of seven reviewers, which included five orthopedic surgeons and two musculoskeletal radiologists, assessed the radiographic healing of SFF based on both the RUS method and the physician impression method. The interobserver and intraobserver reliabilities were calculated using the intraclass correlation coefficient (ICC) and Cohen’s kappa coefficient. The correlation and diagnostic accuracy between RUS and the clinical union were also evaluated. Results: The RUS method resulted in higher intraobserver and interobserver agreement compared to the physician impression method. Inter-rater agreements of the RUS method and physician impression method were moderate (ICC=0.60) and minimal (kappa=0.37), respectively. The RUS method had a higher correlation with clinical union outcome compared to the physician impression method in SFFs (AUC 0.908 versus 0.640). A RUS of 7 or more at 12 weeks had 88% sensitivity and 63% specificity for predicting clinical union outcome. Conclusion: The application of the RUS method is reliable for determining the fracture healing status in SFFs and has better correlation with clinical union than the physician impression method. The RUS method may also be useful for predicting clinical union in SFFs. These results support the use of the radiographic scoring system for fracture healing assessment in SFFs. Keywords: Hip fracture, Subtrochanteric fracture, Fracture healing assessment, Radiographic union, Clinical union, Physician impression

Management of humeral nonunions following failed surgical fixation.

Management of humerus nonunions with previously failed fixation presents a complex problem. There are multiple revision fixation strategies, of which compression plating is a mainstay. The aim of this study was to assess the results of open reduction and direct compression plating without the need for autograft or allograft in the setting of revision humerus open reduction internal fixation. This study is a retrospective analysis of 19 patients treated between 2008 and 2017 for humerus nonunions following failed fixation who were treated by a single surgeon using direct compression plating with bone graft substitutes. Patients were treated with neurolysis of the radial nerve, hardware removal, debridement of the nonunion site with shortening osteotomies, compression plating, and augmentation with bone graft substitutes. All patients were followed until radiographic and clinical union. Nineteen patients were identified for the study and 17 had adequate follow-up for final analysis. Humeral union was achieved in 16/17 (94.1%) patients with a mean time to union of 23weeks. Two patients required a repeat compression plating with bone graft substitute to achieve union. The one patient with a nonunion radiographically reported minimal clinical symptoms and opted for no revision surgery. An association with the index procedure was seen, as three out of four of the patients who experienced radial nerve palsies after their index procedure subsequently experienced a radial nerve palsy after the procedure to repair their nonunion. All patient's all experienced a return of function in their radial nerve either back to baseline or improved from before the revision nonunion surgery. The use of humeral shortening osteotomy and compression plating without autograft or allograft is a viable option for management of humeral nonunions which avoids the morbidity associated with autograft harvest. The patients with radial nerve palsy after the index procedure are likely to have a transient radial nerve palsy as well after the revision surgery necessitating proper informed consent prior to the operation.

Functional Outcomes of Clavicular Fractures Fixation in Adolescent Children

Background: Fractures of the clavicle are common in both adults and children. Recent studies in the treatment of adult fractures have indicated that improved outcomes are achieved after open reduction and internal fixation. The aim of this study was to conduct a retrospective study of the functional outcomes after open reduction and internal fixation of displaced clavicle fractures in adolescent children. Material and Methods: We analysed a retrospective case series of 28 adolescent children who had displaced fractures of the clavicle which were treated with open reduction and internal fixation. The rate of healing, radiographic outcomes, functional outcomes, and complications were looked at. Results: There were 28 children with an average age of 13.8 years (range 13-16 years) had their closed unilateral clavicle fractures treated with open reduction and internal fixation. All the patients were boys. The right side was affected in 14 patients and the left in 14. There were 26 mid-shaft fractures and two lateral-end fracture. Patients were followed for an average of 12 months. There were no superficial or deep infections and all cases went on to clinical and radiological union. Twenty-four (86%) of children returned to unrestricted sporting activity. The mean QuickDASH score at 12 months was 3.24. Four patients had scar sensitivity, and four had plate prominence. Ten patients required metalwork removal. Conclusion: Historically, almost all clavicle fractures in children were treated non-operatively regardless of the displacement and the location of fractures, with variable outcomes. We conclude that open reduction and internal fixation of displaced clavicle shaft fractures in older children can be performed safely and gives predictable results especially with healing periods and functional outcomes.

Tibial osteosynthesis with type II external skeletal fixator in a goat

This study aimed to report the case of a goat with a transverse tibial fracture submitted to osteosynthesis with type II external skeletal fixator. A goat was seen at the Veterinary Hospital Adílio Santos de Azevedo of the IFPB on the Sousa - Paraíba campus, complaining of lameness of the left pelvic limb, and a transverse closed fracture in the middle third of the tibia was diagnosed. External immobilization of the limb with plaster was performed, but there was no improvement, requiring osteosynthesis with the use of type II external skeletal fixator. The limb support of the operated limb was observed the day after the surgery. The skin stitches were removed thirteen days after the surgical procedure, as the wound was healed and unchanged. The animal was hospitalized during the first 25 days after surgery, after which the animal was sent back to the property with the recommendation of cleaning the external skeletal fixator every two days and isolating the animal until removal. Sixty-eight days after the surgical procedure, the animal was without supporting the limb, with purulent secretion draining through the pins path and a penetrating wound in the lateral region of the pelvic limb, looseness of the pins, and pain on manipulation. Radiographic examination revealed bone lysis along the pins' path. The implant was removed and medication with antibiotics and analgesics was prescribed. After twenty days of this last visit, the animal returned to the HV with the wounds healed, without pain on palpation and intermittent support of the limb, and may also observe a deviation at the fracture site due to bad bone union. It is concluded that despite the post-surgical complications, the animal recovered of the fracture with the use of a type II external skeletal fixator because even though there was no continuity of adequate post-surgical management, there was a clinical union of the fracture.