Femoral Nonunion Research Articles

Vancomycin-nanofunctionalized peptide-enriched silk fibroin to prevent methicillin-resistant Staphylococcus epidermidis-induced femoral nonunions in rats.

Implant-related infections and infected fractures are significant burdens in orthopedics. Staphylococcus epidermidis is one of the main causes of bone infections related to biofilm formation upon implants. Current antibiotic prophylaxis/therapy is often inadequate to prevent biofilm formation and results in antibiotic resistance. The development of bioactive materials combining antimicrobial and osteoconductive properties offers great potential for the eradication of microorganisms and for the enhancement of bone deposition in the presence of infections. The purpose of this study is to prevent the development of methicillin-resistant S. epidermidis (MRSE)-infected nonunion in a rat model. To this end, a recently developed in our laboratories bioactive material consisting of antibiotic-loaded nanoparticles based on carboxylic acid functionalized hyperbranched aliphatic polyester (CHAP) that are integrated into peptide-enriched silk fibroin sponges with osteoconductive properties (AFN-PSF) was employed, whose biocompatibility and microbiological tests provided proof of its potential for the treatment of both orthopedic and dental infections. In particular, non-critical femoral fractures fixed with plates and screws were performed in Wistar rats, which were then randomly divided into three groups: 1) the sham control (no infection, no treatment); 2) the control group, infected with MRSE and treated with peptide-enriched silk fibroin sponges incorporating non-drug-loaded functionalized nanoparticles (PSF); 3) the treated group, infected with MRSE and treated with peptide-enriched silk fibroin sponges incorporating vancomycin-loaded functionalized nanoparticles (AFN-PSF). After 8 weeks, bone healing and osteomyelitis were clinically assessed and evaluated by micro-CT, microbiological and histological analyses. The sham group showed no signs of infection and complete bone healing. The PSF group failed to repair the infected fracture, displaying 75% of altered bone healing and severe signs of osteomyelitis. The AFN-PSF treated group reached 70% of fracture healing in the absence of signs of osteomyelitis, such as abscesses in the cortical and intraosseous compartments and bone necrosis with sequestra. AFN-PSF sponges have proven effective in preventing the development of infected nonunion in vivo. The proposed nanotechnology for local administration of antibiotics can have a significant impact on patient health in the case of orthopedic infections.

Management of Infected Femoral Nonunion by Arched External Fixator Augmented by Flexible Intramedullary Nails

Abstract Purpose: The aim of this study is to evaluate the functional and radiological outcome of the management of infected femoral nonunion by arched frame augmented by flexible intramedullary nails. Patients and Methods: In this retrospective case series study, 20 cases were included. All patients had chronically infected nonunited fracture femur. The mean age of the included patients was 33 years. The site of the femoral fracture was midshaft in 12 patients, proximal third of femur in 6 patients, and distal third in 2 cases. Initially, the fracture was open in 17 patients and closed in 3 patients. Four of the included patients had diabetes mellitus. Ten cases were smokers and six of them were heavy smokers. All cases were managed by arched frames, augmented by flexible intramedullary nails. Functional and radiological evaluation was performed using the Association for the Study and Application of the Methods of Ilizarov (ASAMI) scoring system. Results: The mean follow-up was 18.45 months. All cases achieved union except two cases (10%). According to ASAMI bony score, 11 patients (55%) were excellent, 6 (30%) were good, 1 was fair (5%), and 2 (10%) showed poor results. According to ASAMI functional score, 3 patients were excellent, 15 (75%) were good, 3 (15%) were fair, and 2 (10%) showed poor results. Conclusion: The management of infected nonunion of the femur by arched frame and intramedullary flexible nails provides a stable fixation, with acceptable functional and radiological results. Level of Evidence: Level IV case series study.

The Management of Aseptic Non-unions of Distal Femur Fractures with Anatomical Lateral Locking Plates.

Distal femoral non-unions are challenging, and frequently associated with short distal fragments, poor bone stock, and with issues from previous implants. A retrospective study of 31 patients admitted with distal femoral non-unions treated using anatomical lateral locking plates. Non-union scores were used. The Knee Society and Neer's scores were used for the comparison of results. The mean follow-up was 39.5 months (from 24 months to 60 months). Stable union was accomplished in all. There was a significant improvement in the average Neer's score (24 preoperative to 82 post-operatively at final follow-up), the Part 1 Knee Society score from an average of 46 preoperatively to 84 post-operatively, and Part 2 Knee Society score from 36 preoperatively to 80 post-operatively. Optimal stability, good compression at the non-union site (either by lag screws or a compression device or both), maintaining the axial alignment strictly, freshening of bone ends, using an adequate amount of cortico-cancellous bone graft, respecting the biology along with the correct choice of the implant (including the size) are essential to achieve union at the fracture site. Paying attention to the basic principles of management, good contact, stability and maintaining biology is essential in the treatment of non-union. Mukhopadhaya J, Ranjan R, Sinha AK, et al. The Management of Aseptic Non-unions of Distal Femur Fractures with Anatomical Lateral Locking Plates. Strategies Trauma Limb Reconstr 2022;17(3):137-143.

Management of aseptic non-union of shaft femur using intramedullary nailing combined with bone grafting: a case report

<p>Despite the advances in trauma care, improved surgical techniques, latest implants and therefore the evolution of new adjuvants to healing, biologic agents, non-union still persists thanks to high energy trauma as initial event. Non-union of femur shaft represents a significant socioeconomic problem to the patient, related to prolonged patient morbidity, inability to return to figure, gait abnormality, re-operations and psycho-emotional impairment. Here we discuss the case of such non-union of fracture shaft femur presented to us with shortening of 3.5 cm managed with bone graft and intramedullary nailing. 22-year-old male patient had a history of trauma due to fall from bike due to dash from behind by tractor (high velocity road traffic accident) sustaining injury over right thigh leading to closed fracture mid-shaft femur of the same side treated immediately by femur nailing. After 6 months post-surgery, he noticed swelling over operated thigh which was increasing and causing difficulty in walking. X-rays revealed broken nail, re-operated at the same centre with dynamic compression plating (DCP) probably after freshening the fracture edges using 12-hole DCP, implant failure with whole plate and screw construct extrusion and re-fracture at the same site. This time patient presented to our institute. We planned of implant removal and intramedullary nailing with bone grafting. Management of aseptic femoral non-union with fracture gap of 2.5-4 cm range with intramedullary nailing combined with autologous fibular cortical and cancellous grafts showed good functional results at the end of 1 year post operative interval after prior repetitive failure of implants due to non-union. </p>

Accordion maneuver with Ilizarov placed plate in situ, in a case of femoral shaft non-union and refracture with quiescent infection, discussion on treatment strategies: a case report

Introduction: Aim of this study to evaluate the clinical efficacy and highlight their relevance in present orthopedics practice where multiple newer choices have been become famous. Accordion maneuver design with modified Ilizarov apparatus, a single stage procedure in femoral shaft non-union and re-fracture with quiescent infection place dynamic compression plate (DCP) in situ. Femoral shaft fractures (FSFs) are frequently occurring injury due to RTA. Infection (0.4%) and non-union (1.1 - 14%) are the morbid complications of femur fractures. The healing rate for femora shaft non-unions is too high (90%).1 Accordion Maneuver (AM) is the “Bloodless Stimulation” of bone healing described by Professor G. A. Ilizarov. It comprises of alternate compression and distraction which produce stress in living tissue and also convert biologically inactive scar tissue at non-union site into tissue capable of neo-osteogenesis.2 The suggested treatment for quiescent type of infected non-union is a single stage procedure with minimal or no debridement and if implant is provide sufficient stability it placed in situ.3 Case Report: In the case, a 26 years man treated by DCP with MIPO for his Gustilo type – Ⅰ open, comminuted fracture of mid femoral shaft (Left) following RTA. Post-operative infection occurred within 2 weeks of operation. Infection controlled by exploration and surgical toileting with antibiotic. After four (4) months later he was sustained re-fractured with bending plate due to fall again. Finally he was diagnosed as H. Rosen`s type 3 Quiescent infected non-union (Oligotrophic) and Romano stage -1 post-implant infection with re-fracture mid shaft of left femur. Then he was treated following accordion principles with modified Ilizarov frame. AM was applied according to protocol of Baruah and Patowary of non-union treatment. Result: After complete union and consolidation, substantiated by radiological evidence Ilizarov apparatus was dispelled six (6) months later of installation without removal of plate and four (4) months of that finally plate was removed. After one (1) year and four (4) months of mounted Ilizarov frame, the patient was in full free movement of knee and hip. He had no problem during walking even running. Conclusion: We pursue for the treatment, accordion maneuver with Ilizarov apparatus, a single stage procedure in femoral shaft non-union and re-fracture with quiescent infection kept plate in situ. Few authors reported, Accordion Maneuver (AM) techniques with Ilizarov apply over intramedullary nail (IMN) in situ for aseptic non-union of femur. In this study, we discussed the role of this tool (AM) for the treatment of femoral shaft non-union and re-fracture with quiescent infection place plate (DCP) in situ.

Endosteal plating for the treatment of malunions and nonunions of distal femur fractures.

To describe the surgical technique and the outcome of a case series of nonunion and malunion of distal femur fractures treated with an endosteal medial plate combined with a lateral locking plate and with autogenous bone grafting. We retrospectively analyzed a series of patients with malunion or nonunion of the distal femur treated with a medial endosteal plate in combination with a lateral locking plate, in a period between January 2011 and December 2019, Database from chart review was obtained including all the clinical relevant available baseline data (demographics, type of fracture, mechanism of injury, time from injury to surgery, number of previous surgical procedures, type of bone graft, and type of lateral plate). Time to bone healing, limb alignment at follow-up and complications were documented. Ten patients were included into the study: 7 male and 3 female with mean age of 48.3years (range 21-67). The mechanism of trauma was in 8 cases a road traffic accident and in 2 cases a fall from height. According to AO/OTA classification 5 fractures were 33 A3, 3 were 33 C1, 1 was 33 C2 and 1 was 33 C3. The average follow up was 13.5months. In all cases but one bony union was achieved. Bone healing was observed in average 3.3months after surgery. No intraoperative or postoperative complications were reported. A medial endosteal plate is a useful augmentation for lateral plate fixation in nonunion or malunion following distal femur fractures, particularly in cases of medial bone loss, severe comminution, or poor bone quality. Level IV (retrospective case series).

Operative treatment of nonunions in the elderly: Clinical and radiographic outcomes in patients at minimum 75 years of age

BackgroundLimited information exists on nonunion treatment in the elderly. This retrospective study evaluates whether results of operative treatment of nonunion of the humerus or femur in patients aged ≥ 75 years are comparable to those in younger patients.MethodsWe identified patients age ≥ 75 years with a nonunion of humerus or femur treated with open reduction and internal fixation. The Non-Union Scoring System was calculated. Complications, clinical outcome, and radiographic findings were assessed. Primary endpoint was nonunion healing. A literature review compared time to healing of humeral and femoral nonunion in younger populations.ResultsWe identified 45 patients treated for a nonunion of humerus or femur with > 12 months follow-up. Median age was 79 years (range 75–96). Median time to presentation was 12 months (range 4–127) after injury, median number of prior surgeries was 1 (range 0–4). Union rate was 100%, with median time to union 6 months (range 2–42). Six patients underwent revision for persistent nonunion and healed without further complications.ConclusionsUsing a protocol of debridement, alignment, compression, stable fixation, bone grafting and early motion, patients aged 75 years or older can reliably achieve healing when faced with a nonunion of the humerus or femur.Level of Evidence: IV.

Induced Membrane Technique for the Management of Segmental Femoral Defects: A Systematic Review and Meta-Analysis of Individual Participant Data.

Several modifications of the induced membrane technique (IMT) have been reported, but there is no consensus regarding their results and prognosis. Moreover, most studies have focused on tibial defects; no meta-analysis of the treatment of femoral defects using the IMT has been reported. This systematic review and meta-analysis aimed to identify the potential risk factors of post-procedural complications following the treatment of segmental femoral defects using the IMT. A comprehensive search was performed on the Cochrane Library, EBSCO, EMBASE, Ovid, PubMed, Scopus, and Web of Science databases, using the keywords "femur," "Masquelet technique," and "induced membrane technique." Original articles composed in English, having accessible individual patient data, and reporting more than two cases of bony defect or nonunion of femur or more than five cases of any body part were included. Post-procedural bone graft infections, final union status, and union time after second-stage operation were analyzed. Fourteen reports, including 90 patients, were used in this study. External fixation in second-stage surgery had an odds ratio of 9.267 for post-procedural bone graft infection (p=0.047). The odds ratio of post-procedural bone graft infection and age >65 years for final non-union status was 51.05 (p=0.003) and 9.18 (p=0.042). Shorter union time was related to impregnated antibiotics in the spacer (p=0.005), transplanting all-autologous grafts (p=0.042), and the application of intramedullary nails as the second-stage fixation method (p=0.050). The IMT appears to be reasonable and reproducible for femoral segmental bone defects. Several preoperative and surgical factors may affect post-procedural complications and union time.

Single-cell RNAseq provides insight into altered immune cell populations in human fracture nonunions.

Nonunion describes bone fractures that fail to heal, resulting in the fracture callus failing to fully ossify or, in atrophic cases, not forming altogether. Fracture healing is regulated, in part, by the balance of proinflammatory and anti-inflammatory processes occurring within the bone marrow and surface cell populations. We sought to further understand the role of osteoimmunology (i.e., study of the close relationship between the immune system and bone) by examining immune cell gene expression via single-cell RNA sequencing of intramedullary canal tissue obtained from human patients with femoral nonunions. Intramedullary canal tissue samples obtained by reaming were collected at the time of surgical repair for femur fracture nonunion (n = 5) or from native bone controls when harvesting autologous bone graft (n = 4). Cells within the samples were isolated and analyzed using the Chromium Single-Cell System (10x GenomicsInc.) and Illumina sequencers. Twenty-three distinct cell clusters were identified, with higher cell proportions in the nonunion samples for monocytes and CD14 + dendritic cells (DCs), and lower proportions of T cells, myelocytes, and promyelocytes in nonunion samples. Gene expression differences were identified in each of the cell clusters from cell types associated with osteoimmunology, including CD14 + DC, monocytes, T cells, promyelocytes, and myelocytes. These results provide human-derived gene profiles that can further our understanding of pathways that may be a cause or a consequence of nonunion, providing the clinical rationale to focus on specific components of osteoimmunology. Clinical significance: The novel single-cell approach may lead to clinically relevant diagnostic biomarkers during earlier stages of nonunion development and/or investigation into therapeutic options.

The Reamer-Irrigator-Aspirator (RIA) System for the treatment of aseptic femoral nonunions: Report of two cases and literature review.

Femoral shaft nonunions are disabling complications of fractures, with relevant socioeconomic and psychological impact. The incidence of femoral shaft nonunions is not negligible, ranging between 1% and 10% after intramedullary nailing, but can exceed 20% in case of subtrochanteric fractures. Treatment options are influenced by pathomechanical, anatomical, and clinical factors. Hypertrophic nonunions are usually treated by enhancing stability of fixation, while atrophic nonunions require additional biological stimulation to achieve bone union. The Reamer-Irrigator-Aspirator (RIA) System® was developed to reduce intramedullary pressure and heat generation during intramedullary reaming, thus preventing thermal necrosis and decreasing the risk of fat embolism. The RIA System allows to provide large volumes of high-quality morselized autologous bone, that has shown high osteogenetic and osteoinductive properties. Therefore, its use has been expanded as a valuable source of autologous bone graft for the treatment of large bone defects of different nature. In this article, we present two cases of complex femoral nonunions treated with the use of the RIA System. A review of the published literature on the treatment of femoral nonunions with RIA was also performed. Core tip: In case of atrophic nonunions, the RIA System can be used to obtain biologically active tissue to enhance bone healing. Despite the absence of high-quality studies focused on femoral nonunions, the efficacy of RIA is well-known and orthopaedic surgeons should be aware of this powerful tool.

115 Management of Femoral Non-Union with Post-Traumatic Bone Defect Using Second-Generation PRECICE® Nail - a Case Report

Abstract Introduction The management of post-traumatic bone defects with non-union remains a surgical challenge. Common limb length discrepancy (LLD) procedures involve Masquelet technique, vascularised bone grafts, distraction osteogenesis using external fixators, yet they pose a functional and economical challenge for patients, given high complication rates and need for revision surgery. Magnetically driven PRECICE nails are self-lengthening internal devices activated via an external controller. We present one patient with post-traumatic femoral non-union with concomitant bone defect, using second-generation PRECICE nail. Case Study One 57-year-old gentlemen suffered open femoral fracture after a motorcycle accident. Having previously undergone open reduction internal fixation, he presented to us with atrophic non-union and bone defect, which were simultaneously treated with a second-generation PRECICE nail. Our treatment protocol was based on the strain theory and involved initial distraction by ∼5mm at non-union site, at a rate of 1mm per day, to decrease strain on bone graft cells and promote callus formation. One week later, the non-union site was compressed to close the gap completely. After another four weeks, distraction using the PRECICE nail started, in increments of 0.25mm, four times a day, until the desired length was achieved. The patient achieved union and the initially planned limb lengthening regime was achieved with minimal complications. Conclusions By initially distracting the bone defect by ∼5mm, then compressing the gap, before distraction started, strain on bone graft cells was minimised, allowing robust callus and regenerate growth. Self-lengthening, magnetically driven PRECICE nails can successfully restore union and manage limb length discrepancies with reasonable patient satisfaction and minimal complications.

Fixed-angle plate fixation and autogenous iliac crest graft for repair of distal metaphyseal femoral nonunion.

To analyze clinical, radiographic and patient-reported outcomes of distal metaphyseal femoral nonunions treated with fixed-angle plates and screws. All patients presenting with a distal metaphyseal femoral fracture nonunion repaired with fixed-angle plating from one urban level 1 trauma center and an orthopedic specialty hospital were identified. Baseline demographic, injury information, and outcomes (healing rates, Short Musculoskeletal Function Assessment, range of motion, and post-operative pain levels) at 12months following nonunion repair were collected. Outcomes were evaluated between patients fixed with a blade plate and with a locking plate. Of these 31 patients, 27 (87.1%) healed after their index nonunion surgery, 2 (6.5%) healed after one reoperation, 1 (3.2%) healed after 2 reoperations, and 1 (3.2%) had a persistent nonunion but did not want further treatment. At one-year follow-up, the group demonstrated a significant improvement in functional recovery with a mean difference of 14.5 points (p = 0.007) when compared to status before fixed-angle fixation of the nonunion. There was also a significant change in patient-reported pain levels using the VAS scale with a mean difference of 2.0 points (p = 0.009). At one-year follow-up, 11 (39.3%) had full knee range of motion (0-130), 11 (39.3%) had flexion greater than 90 and less than 120°, and 6 (21.4%) had range of motion less than 90°. Patients who undergo fixed angle plating and autogenous bone grafting for distal femoral metapyseal nonunionsdemonstrate improved functional outcomes and VAS pain score at one year follow up.

Extrusion-based additive manufacturing of Mg-Zn/bioceramic composite scaffolds

The treatment of femoral nonunion with large segmental bone defect is still challenging. Although magnesium alloys have been considered potential materials for such a treatment, their application is limited by their fast degradation. Adding bioceramic particles into magnesium to form Mg-matrix composites is a promising strategy to adjust their biodegradation rates and to improve their mechanical properties and cytocompatibility further. Here, we developed an extrusion-based additive manufacturing technique to fabricate biodegradable Mg-Zn/bioceramic composite scaffolds ex-situ. Inks carrying a Mg-Zn powder and 5, 10 and 15% β-tricalcium phosphate (TCP) powder particles were investigated regarding the dispersion of β-TCP particles in the inks and viscoelastic properties. Optimally formulated inks were then employed for subsequent 3D printing of porous composite scaffolds. The in vitro biodegradation rate of the scaffolds containing 5% β-TCP decreased to 0.5mm/y, which falls within the range desired for critical-sized bone substitution. As compared to the monolithic Mg-Zn scaffolds, the elastic moduli and yield strengths of the composite scaffolds were much enhanced, which remained in the range of the cancellous bone properties even after 28 d of in vitro degradation. The Mg-Zn/5TCP and Mg-Zn/10TCP scaffolds also exhibited improved biocompatibility when cultured with preosteoblasts, as compared to Mg-Zn scaffolds. In addition, the ALP activity and mineralization level of the composite scaffolds were much enhanced in the extracts of the composite scaffolds. Taken together, this research marks a great breakthrough in fabricating porous Mg-matrix composite scaffolds that meet several design criteria in terms of appropriate biodegradation rate, mechanical properties, and bioactivity. STATEMENT OF SIGNIFICANCE: The treatment of posttraumatic femoral nonunion with large segmental bone defect is still challenging. In this study, we developed a multi-material extrusion-based additive technique to fabricate porous Mg/bioceramic composite scaffolds for such a treatment. The technique allowed for the fine-tuning of printable inks to optimize the dispersion of micro-sized particles. The relative densities of the struts of the fabricated composite scaffolds reached 99%. The added bioceramic particles (β-TCP) exhibited proper interfacial bonding with the Mg alloy matrix. The porous Mg-based composite possessed desired biodegradability, bone-mimicking mechanical properties throughout thein vitrobiodegradation period and improved bioactivity to bone cells. These results demonstrated great prospects of extrusion-based 3D printed porous Mg materials to be developed further as ideal biodegradable bone-substituting materials.

Observation of role of orthofix limb reconstruction system in with non-union with bone loss lengthening due to fresh fractures

The concept of Bifocal osteos1ynthesis is distraction at the Osteotomy site and compression at the non-union site with rhythmical distraction leads on the neo-osteogenesis and consolidation of cortectomy site. Transporting a segment of bone increases the vascularity of the fracture ends. Once the vascularity of the fracture ends increases, the infection will be eradicated and there will be healing of non-union. Daring transportation phase for bone lengthening their Wet pin tract infection and loosening in two cases for which pin Tension was done. ln all cases, neither there was infection at the Corticectomy site nor at the distraction sites. After a period of Waiting for consolidation to occur, the final result of the healing of the osteotomy was adequate in all cases. The cases (seven) with limb length discrepancy up to 2.5 cms in lower limb managed with modified footwear with heel and sole raise. One case of femur nonunion had angular deformity of 15 degrees. Six cases had knee stiffness; three cases had ankle stiffness. There was no neurological or vascular injury as a result of instrumentation. Bone healing index was (days of fixator use/centimeters of length gain) 69.1 days/cm.

The technique of "autologous bone grafting through channels" combined with double-plate fixation is effective treatment of femoral nonunion.

The aims of this retrospective study were to evaluate the effective treatment of femoral nonunion using the technique of "autologous bone grafting through channels" combined with double-plate fixation. In this study, 186 patients with nonunion fracture of femur who underwent surgery using the technique of "autologous bone grafting through channels" combined with double-plate fixation in Hong Hui Hospital from May 2010 to July 2020 were enrolled. Totally, 122 males and 64 females with mean age of 44years were evaluated. These patients were evaluated for the full clinical and radiological union time, duration of follow-up, levels of post-operative limb shortening, and range of motion of adjacent joints, and incidence of serious complications. The mean follow-up time was 22 ± 6.2months (range 12-44months). Mean union time from surgery using our technique to full clinical and radiological union was 7.6 ± 1.2months (range 4-9months). All patients have achieved the union after one operation or two operations using the technique. The one-operation union rate is 98.4%. Post-operative severe complications were seen in seven patients which included deep vein thrombosis; the surgical site infection and the fracture nonunion. The range of motion in the adjacent joint of 17.7% (33/186) in all patients have an effect to the limb function. Six patients have the limb shortening more than 10mm after surgery. The technique of "autologous bone grafting through channels" combined with double-plate fixation is showed to be safe, effective, and easy to master and operate surgical option for treating the femoral nonunion.

The efficacy of dynamic compression locking system vs. dynamic hip screw in the treatment of femoral neck fractures: a comparative study

BackgroundThere is still a lack of consensus on which internal fixation method can better maintain the stability of femoral neck fractures (FNF), promote fracture healing, and reduce postoperative complications such as femoral head necrosis and nonunion. Therefore, the purpose of this study was to evaluate the clinical efficacy of the novel dynamic compression locking system (DCLS) versus dynamic hip screw (DHS) in the treatment of FNF.MethodsFifty cases of FNF from July 2018 to February 2020 were retrospectively analyzed. According to different treatment methods, they were divided into DCLS group (26 cases) and DHS group (24 cases). Baseline data, intraoperative and postoperative clinical data, reoperation rate, and Harris score were collected to evaluate the clinical efficacy.ResultsAll patients were followed up for 24 months. All “fractures” were caused by fall. The baseline data of the two groups were comparable (P > 0.05). There weren’t significant differences in the length of hospital stay and mobility after two years postoperatively between the two groups (P > 0.05). The operation time, blood loss, incision length, fluoroscopy times and the degree of femoral neck shortening after two years postoperatively in the DCLS group were significantly less than those in the DHS group (all P < 0.05). Harris score after two years postoperatively in the DCLS group was significantly higher than that in the DHS group (P < 0.05). Although the reoperation rate in the DHS group was slightly higher than that in the DCLS group, it wasn’t statistical significance (P > 0.05).ConclusionsCompared with DHS, DCLS in the treatment of FNF had less surgical trauma, shorter incision length, shorter operation time, lower radiation dose and higher Harris scores. Although the reoperation rate in the DHS group was slightly higher than that in the DCLS group, it wasn’t statistical difference. Further research is needed.

Aseptic femoral nonunion treated with exchange locked nailing with intramedullary augmentation cancellous bone graft

BackgroundClosed reamed locked intramedullary nailing has been the treatment of choice for most of femoral shaft fractures. A high union rate with a low complication rate is generally predictable. For an aseptic femoral shaft nonunion with a prior inserted intramedullary nail, exchange nailing is one of favored surgical techniques for treatment. However, a greatly varied success rate of 72–100% has been reported. To improve the success rate of exchange femur nailing, a modified bone grafting technique was developed. The purpose of this retrospective study intended to evaluate outcomes of such a revised technique.MethodsFrom July 2011 to March 2019, 48 consecutive adult patients (average, 38 years; range, 19–67 years) with aseptic femoral shaft nonunions after intramedullary nailing treatment were studied. All femoral shaft fractures were initially caused by traffic accidents, which were treated by a closed or open intramedullary nailing technique at various hospitals. The current revision treatment was performed after an average of 2.2 years (range 1.1–6.2 years) from initial injuries. In the surgery, the prior nail was removed and the marrow cavity was reamed widely (at least 2 mm as possible). Sufficient cancellous bone grafts harvested on the trochanteric marrow wall from the inside were placed in the marrow cavity of the junction of nonunion fragments. A new 1-mm smaller size locked intramedullary nail was inserted. Whether the dynamic or static mode of nails were used mainly depended on the nonunion level. Postoperatively, protected weight bearing with crutches was allowed for all patients.ResultsForty-one patients were followed for an average of 2.8 years (85.4%; range, 1.9–4.5 years) and all fractures healed. The union rate was 100% (41/41, p < 0.001) with a union time of an average of 3.4 months (range, 2.5–5.0 months). There were no complications of deep infection, nonunions, malunions, implant failures or an avulsed trochanter tip fracture. The satisfactory knee function improved from 73.2% (30/41) preoperatively to 92.7% (38/41) at the latest follow-up (p = 0.019).ConclusionsThe described modified bone grafting technique may effectively improve a union rate of exchange femur nailing while the surgical procedure is not complicated. It may therefore be used concomitantly in all aseptic femoral shaft nonunions when exchange nailing is performed.

Revision Surgery Using Retrograde Nail versus Replating in Nonunion Distal Femur Fracture Treated with Plate.

Articular distal femur fractures represent 4% to 6% of femur fractures. Locking compression plates (LCPs) are the main treatment option. Nevertheless, a reoperation rate of 12.9% has been reported; nonunion is reported at 4.8%, delayed union at 1.6%, and malunion at 0.6%. Treatment of nonunions can be challenging as no unanimous consensus regarding the best surgical technique has been reached. The aim of this study was to evaluate and compare two types of revision surgery as treatment of LCP-treated articular distal femoral fracture nonunion: retrograde nail or replating. A retrospective cohort study of patients admitted from January 2015 to February 2017 for nonunion of AO/OTA 33C2 fractures previously treated with a lateral LCP was conducted. Patients were treated either with intramedullary nailing (Group A) or with replating (Group B). One independent observer performed clinically and radiographically followed up at 1, 3, 6, 9, 12, 24, and 36 months after surgery. The nonunion scoring system (NUSS) was used. Nine patients were included in our study. The mean follow-up was 2 years. Five patients were treated with intramedullary nailing and four with replating. The NUSS score was 24.2 ± 6.8 in the nailing group and 37.3 ± 3 in the replating group (P=0.03). In the nailing group, radiographic consolidation was obtained in all cases. In the replating group, nonunion was found in 3 patients and failure of osteosynthesis in one patient. Therefore, four patients (Group B) underwent implant removal and retrograde femoral nailing, obtaining radiological healing. The union time was 7.6 months in the nailing group. Retrograde intramedullary nailing can be used as an effective treatment of aseptic AO-33C distal femoral nonunion following primary locking plating.

Ложные суставы шейки бедренной кости: применение новой классификации при эндопротезировании у пациентов пожилого возраста

Introduction The risk of the femoral neck fracture nonunion is 48 % with avascular necrosis of the femoral head being reported in 42 % of cases. There are many classifications of acute intra-articular fractures of the proximal femur and there are no grading systems for femoral neck nonunions that would allow prediction of outcomes of total hip arthroplasty (THA). The objective was to evaluate mid-term results of THA in patients with femoral neck nonunion and develop a new classification of nonunions. Material and methods A prospective cohort single-center comparative study included 78 elderly patients with atrophic femoral neck nonunions treated with primary THA. The mean follow-up period was 24.2 months. Three prospective groups were identified. Separation criteria included shortening of the lower limb and femoral offset, changes in the Barnett-Nordin index, the Hounsfield bone density index, the presence of metal constructs and bone defects. Groups A and B were divided into 2 subgroups depending on the presence/absence of fixation metal constructs for a femoral neck fracture. Group C was divided into 2 subgroups: type C1, acetabular defect and type C2, proximal femur defect. Results Mean operating time was 81.1 minutes in group A, 102.9 minutes in group B and 145.2 minutes in group C. The minimum blood loss was recorded in group A measuring on average 429.25 mL in both subgroups. The maximum blood loss was seen in patients of groups B and C measuring 606.62 mL and 631.5 mL. Overall revision rate was 7.7 %. Conclusion A classification for femoral neck nonunions was developed suggesting grading patients into 3 types: type A, type B and type C which were further divided into 2 subtypes. The grading system was based on lower limb shortening and femoral offset, severity of osteoporosis, presence of metal constructs and acetabulum or proximal femur bone defect which prognostically affected the outcome of THA.

Bloqueio paravertebral lombar em coelho (Oryctolagus cuniculus) submetido à amputação de membro pélvico - relato de caso

ABSTRACT The concern about pain management in exotic mammals is increasing. However, only a few studies describe locoregional anesthesia techniques in rabbits. Thus, this report aims to describe the lumbar paravertebral block, guided by peripheral nerve stimulation, in a rabbit undergoing mid-femoral amputation. We received a one-year-old rabbit weighing 1.27kg with a history of non-union of the right femur and osteomyelitis. The animal came to us for high pelvic limb amputation. After premedication with ketamine, midazolam, and morphine, the patient was maintained under general anesthesia in a non-rebreathing circuit under spontaneous ventilation with isoflurane vaporized in 0.6 oxygen. Using a peripheral nerve stimulator, we performed the lumbar paravertebral block, positioning the needle between the L5 and L6 vertebrae and injecting 0.2mL/kg bupivacaine. The patient remained stable throughout the procedure, without the need for analgesic rescue with opioids during surgery and postoperatively. The discharge occurred after 24 hours. The lumbar paravertebral block proved efficient for trans and postoperative analgesia for high pelvic limbic amputation in rabbits.