Femoral Nonunion Research Articles

Fixator-Assisted Nailing for Femur Neck Fracture Nonunion: A Case Series Study.

Background Femoral neck fractures in young adults tend to be a result of high-energy trauma with a common pattern of Pauwels type III fracture, and they require timely and meticulous diagnosis and management. The objective of this study was to assess the clinical and radiological outcomes of the fixator-assisted nailing technique for managing femur neck fracture nonunion. Methods. This was a case series study of 16 patients with nonunion femoral neck fractures treated via a fixator-assisted nailing technique. Our inclusion criteria comprised the inclusion of any patient between the ages of 14 and 60 years old with a neglected neck of femur fracture or nonunion of the femur neck. In addition, we only included patients without further posttreatment trauma and without known metabolic diseases. The conditions that were excluded from this study included hip joints with preexisting osteoarthritis, radiographic evidence of avascular necrosis of the femoral head, and associated ipsilateral acetabulum fracture or fracture-dislocation. The fracture characteristics that were selected for the fixator-assisted nailing (FAN) technique were clear signs of pseudoarthrosis (such as sclerosis, clear fracture line defects, and failure of implants), in addition to evidence of varus malalignment. All fractures were Pauwels type III. Radiographs of the pelvis with both hips and a posteroanterior (PA) view of the injured hip were taken. Full weight bearing was allowed in all the patients from the first day postoperatively. Physical therapy was started for pain reduction modalities, stretching, and abductor strengthening. Results Union of the femur neck fracture and osteotomy site was achieved in all patients. An excellent functional status after four months of follow-up was found based on a modified Harris hip score questionnaire. At follow-up, no patient was suffering from pain or flexion contracture. Preoperative limb length discrepancy (LLD) (cm) was 1.8 ± 0.8 cm and postoperative was 0 ± 0.1 cm, p < 0.001. Preoperative neck-shaft angle (NSA) (o) was 85.6 ± 4.4 and postoperative was 126.9 ± 2.5, p < 0.001. Preoperative Pauwels angle (o) was an average of 50.4 ± 5.9 and postoperative was 31.3 ± 2.5, p < 0.001. Conclusion Our study indicates that FAN has a high success rate in young patients with nonunited femoral neck fractures.

The effect of TLR-4 on the proliferation and differentiation of bone mesenchymal stem cells and its relationship with the Wnt signal transduction pathway during bone nonunion.

BackgroundBone nonunion is a special fracture complication that occurs in about 5% to 10% of cases. This type of fracture is difficult to heal, and causes great pain to patients and affects their quality of life. The mechanism of bone nonunion is not clear. In our study, we investigated the influence of Toll-like receptor (TLR)-3, TLR-4, and Wnt signaling pathways on the occurrence of bone nonunion.MethodsFirstly, we established a Sprague Dawley (SD) rat model of femoral nonunion, and detected the expression levels of TLR-3, TLR-4, β-catenin, nemo-like kinase (NLK), c-Jun N-terminal kinase (JNK), and other proteins during model construction. For in vitro experiments, primary cultured bone mesenchymal stem cells (BMSCs) were divided into 4 groups: lipopolysaccharide (LPS, agonist of TLR-4) group, LPS + CLI095 (inhibitor of TLR-4) group, control group, and LPS + substance P (SP) group. The expression of β-catenin, NLK, JNK, and ALP and the osteogenic differentiation ability of cells were detected during culture.ResultsX-ray and hematoxylin and eosin (HE) staining results confirmed the successful modeling of bone nonunion. During the formation of the bone nonunion model, the expression of TLR-4 showed an upward trend. In vitro experiment results showed that inhibition of TLR-4 expression could enhance the proliferation and differentiation ability of BMSCs. The expression of β-catenin, the core protein of the canonical Wnt signaling pathway, increased rapidly in the first 2 weeks of bone nonunion construction, and decreased after 2 weeks. Non-canonical Wnt signaling pathway proteins NLK and JNK had no change in the first 2 weeks, and showed an upward trend after 2 weeks. In vitro experiment results showed that the expression of β-catenin was dominant in BMSCs with strong proliferation and differentiation ability, while the expression of NLK and JNK was dominant in BMSCs with weak proliferation and differentiation ability. These results suggest that the Wnt signaling pathway may regulate the occurrence of bone nonunion.ConclusionsTLR-4 inhibits the proliferation and differentiation of BMSCs, and the transformation of the canonical Wnt signaling pathway to the non-canonical Wnt signaling pathway may lead to bone nonunion. Our study may provide new insights into the treatment of bone nonunion.

Double fixation for complex distal femoral fractures.

For complex distal femoral fractures, a single lateral locking compression plate or retrograde intramedullary nail may not achieve a stable environment for fracture healing.Various types of double fixation constructs have been featured in the current literature. Double-plate construct and nail-and-plate construct are two common double fixation constructs for distal femoral fractures.Double fixation constructs have been featured in studies on comminuted distal femoral fractures, distal femoral fracture with medial bone defects, periprosthetic fractures, and distal femoral non-union.A number of case series reported a generally high union rate and satisfactory functional outcomes for double fixation of distal femoral fractures.In this review, we present the state of the art of double fixation constructs for distal femoral fractures with a focus on double-plate and plate-and-nail constructs.

The use of megaprosthesis in the treatment of proximal and distal femur nonunions in the elderly

Management of nonunion in the elderly patient are always a challenge for the orthopedic surgeon. The patient’s clinical condition is often critical, and normal nonunion management strategies are burdened with a high rate of failure. Megaprostheses have been designed for the management of bone tumors, but in the literature many cases of use in non-neoplastic conditions are described. They are, however, burdened by a high rate of complications, and in particular dislocations and periprosthetic infections. Proximal and distal femur replacement should therefore be considered as a salvage strategy to be used in the most severe cases of nonunion in the elderly patient.

Evaluation of complications associated with bifocal bone transport as treatment for either proximal, intermediate or distal femoral defects caused by infection: outcome analysis of 76 patients

BackgroundThe purpose of this study was to evaluate the outcomes of bifocal bone transport in the treatment of femoral bone defects caused by infections.MethodsClinical and radiographic data of patients with infected femoral nonunion treated by the bifocal bone transport at our hospital were analyzed retrospectively, from January 2008 to December 2019. Depending on the location of bone defects, the patients were divided into three groups (proximal, intermediate, and distal). The Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria was applied to assess the bone and functional outcomes. Postoperative complications of three groups were documented and compared.ResultsSeventy-six cases of infected femoral bone defects (31 cases of proximal, 19 cases of intermediate, and 26 cases of distal) were managed by bifocal bone transport successfully with a mean follow-up time of 30.8 months (range, 23 to 41 months). There were 58 men (76.3%) and 18 women (23.6%), with a mean age of 38.8 years (range, 23 to 60 years). The bone union was received in 76 cases with a mean of 6.9 months (range, 5 to 8 months). Pin tract infection was observed in twenty-nine cases (38.1%), 7 cases (9.2%) of muscle contractures, 3 cases (7.9%) of joint stiffness, 13 cases (17.1%) of axial deviation, 2 cases (2.6%) of delayed union, one case (1.3%) of nonunion, and none (0%) of transport gap re-fracture. One patient (1.3%) was scheduled for knee arthroplasty when bone transport treatment ended.ConclusionsBone transport using an external rail fixator was a practical method to treat the femoral bone defects, since the satisfactory rate of bone union and limb function recovery. Complications of distal femoral bone transport were more severe than the proximal and intermedia, but the rate of complication was the least of the three groups. Soft-tissue-related complications were more likely to occur in the intermediate bone transport.

Modified use of the proximal humeral internal locking system (PHILOS) plate for distal femoral nonunions

PurposeNonunion is a common complication after a distal femoral fracture (DFF). Standard treatment consists of revision plating and/or bone grafting. Single lateral plating for a distal femoral nonunion can be insufficient in case of a persistent medial gap and compromised bone stock. Alternatively, dual plating can be used to treat a distal femoral nonunion, but to date there is no Gold standard. The aim of our study was to report our results after use of a minimally invasively placed proximal humeral internal locking system (Philos) plate as a medial buttress in the treatment of a distal femoral nonunion.MethodsFifteen adult patients with a distal femoral nonunion were prospectively entered in a trauma database and retrospectively assessed. All patients underwent a similar operation, which included removal of failed hardware, nonunion debridement, fixation with a lateral plate, and a medial Philos plate combined with bone grafting. Data collected included union rate, time to union, complications and functional outcome.ResultsIn twelve out of fifteen patients (80%), the fracture united after our index operation. Median time to union was 4.8 months (range 1.6–15). Three patients (20%) needed additional bone grafting surgery. One patient underwent a Judet quadricepsplasty.ConclusionThis study suggests that the Philos plate is a safe and effective adjunct as a medial buttress plate for distal femoral nonunions.

Biomechanical analysis of two medial buttress plate fixation methods to treat Pauwels type III femoral neck fractures

BackgroundFemoral neck fractures in young people are usually Pauwels Type III fractures. The common treatment method are multiple parallel cannulated screws or dynamic hip screw sliding compression fixation. Due to the huge shear stress, the rate of complications such as femoral head necrosis and nonunion is still high after treatment. The aim of our study was to compare the stabilities of two fixation methods in fixating pauwels type III femoral neck fractures.MethodsAll biomimetic fracture samples are fixed with three cannulated screws combined with a medial buttress plate. There were two fixation groups for the buttress plate and proximal fracture fragment: Group A, long screw (40 mm); Group B, short screw (6 mm). Samples were subjected to electrical strain measurement under a load of 500 N, axial stiffness was measured, and then the samples were axially loaded until failure. More than 5 mm of displacement or synthetic bone fracture was considered as construct failure.ResultsThere were no significant differences in failure load (P = 0.669), stiffness (P = 0.842), or strain distribution (P > 0.05) between the two groups.ConclusionsUnicortical short screws can provide the same stability as long screws for Pauwels Type III Femoral Neck Fractures.

Safety and efficacy of a novel retrograde route for femoral bone graft harvesting by Reamer-Irrigator-Aspirator: a pilot study on 24 patients

BackgroundThe Reamer–Irrigator–Aspirator system was initially developed to reduce fat embolism and thermic necrosis during reamed intramedullary nail fixation of femoral shaft fractures. Currently, this system is used in extended applications including accessing large volume of autologous bone graft, as alternative for iliac crest harvesting. Antegrade femoral bone graft harvesting using the Reamer-Irrigator-Aspirator system is considered the standard technique. The aim of our study is to evaluate the efficacy (bone graft volume) and the complications (blood loss, postoperative pain, and incidence of iatrogenic fractures) of the Reamer–Irrigator–Aspirator system through the retrograde femoral route in a series of patients with post-traumatic bone defects or nonunions.MethodsA non-controlled single center retrospective observational cohort study was conducted in a level1 trauma center to evaluate all patients who were treated using the RIA system. Between November 2015 and May 2019, 24 patients (8 women and 16 men; mean age: 41 years [range 27–55 years]) with bone defects or nonunions underwent bone graft harvesting using the Reamer–Irrigator–Aspirator system through retrograde femoral route. Postoperative pain, complications, and bone graft volume were analyzed. Inclusion criteria was patients older than 18 years with a diagnosis of post-traumatic bone defect or associated tibial or femoral nonunion, with minimum 6-months follow, treated using the RIA. We hypothesized that the retrograde route of the RIA system is a safe and efficacious method for bone harvesting.ResultsThe average volume of collected graft was 45 cc (range 30–60 cc). In 83% of the cases, bone grafting was sufficient, while in 17% it was necessary to add iliac crest bone graft to completely fill the bone defect. A mean drop in postoperative hemoglobin of 4.1 g / dL (range 0.5–6.0 g / dL) was evidenced. In 4 cases (33%), a unit of packed red blood cells was required. Regarding postoperative pain, visual analogue scale after 3 months postoperatively was 1.6 in average. After 6 months, the value has decreased to 0.4. There were no perioperative or postoperative complications at 6-month follow-up.ConclusionIn this limited case series, large volumes of bone graft were harvested using the retrograde route of the RIA system and there were no intra-/ postoperative complications observed at 6-month follow-up. Therefore this novel technique appears safe and efficacious.However, it’s important to highlight that future prospective controlled studies are necessary to validate the insights from this pilot study.

A prospective study on the role of limb reconstruction System in infective non-union of femur and tibia

Introduction: Infected non-union of long bones is the state of failure of union and the persistence of infection at the fracture site for a period of 6 to 8 months or more. This condition possesses a challenge for optimal treatment to the orthopaedic surgeon. Limb reconstruction system (LRS) is a single bar device with telescoping facility which allows increased axial movement at the fracture site by permitting conversion from rigid to dynamic fixation resulting in formation of external bridging callus. The regenerated bone restores length and eliminates infection. This procedure does not require much expertise of the treating orthopaedic surgeon and is associated with high patient compliance.Materials and Methods: 20 adult patients with infective non-union of femur and tibia were admitted in Silchar Medical College and Hospital, Silchar between September 2019 to August 2020 after being diagnosed clinically and radiologically as infective non-union. Preoperative radiographs were taken to assess the type of non-union, presence of infection, implants, quality of bone stock and level of non-union. Patients were classified according to the classification by Rosen et al. in the A.O. manual into quiescent, active and draining types. Follow up was done every 4 weeks and Association for the Study and Application of Methods of Ilizarov (ASAMI) score was used to categorize the outcome into excellent, good, fair and poor.Results: It was observed that 90% patients showed excellent to good functional as well as bone healing outcomes.Discussion: Results of mean bony transport, mean implant index and outcomes are comparable to previous studies conducted.Conclusion: LRS application to infective non-union of long bones is a cost-effective procedure which favours both the surgeon and patient as compared to other available treatment modalities.

Surgical and functional outcomes of infective non union of femur and tibia using ilizarov ring fixator

Introduction: Nonunion of long bone fractures is a common condition encountered by an orthopedic surgeon in daily practice. For effective treatment of nonunion, internal fixation with or without bone grafting can be done but, an infected non union can prove to be a tough challenge. The aim of our study is to assess the surgical and functional outcomes of infected nonunion of femur and tibia treated with debridement, corticotomy and Ilizarov ring fixator. Materials and Method: This was a multi-centric prospective study of twenty patients in a time span of three years from May 2017 till April 2020. Observations and Results: Patients were assessed using clinical and functional results as per Association for the Study and Application of Methods of Ilizarov (ASAMI) Scoring System. Conclusion: The Ilizarov method remains one of the most successful and versatile means of achieving bone-healing in infected nonunion of long bones of lower limbs with benefits of correcting deformities, bone defects and limb length discrepancy.

Outcome of Plate Augmentation in Management of Tibial Nonunion After Intramedullary Nailing

<i>Background:</i> Despite the multitude of studies on non union no clear criterion has been established for declaring a fracture as non united. A diagnosis of non union is unjustified, however, until clinical or radiographic evidence shows that healing has ceased and that union is highly improbable. A fracture of the shaft of a long bone should not be considered a non union until at least 6 months after the injury. The incidence of non union in the long bone varies with each bone and with methods of treating acute fractures. More recently, the tibia probably is the most frequent site of non union. Nonunion following intramedullary fixation of tibial fractures is a challenge. Although reamed exchange nailing results are encouraging with union rates, exchange nailing could be extremely challenging due to situations when nail removal is difficult. Augmentation plates gained popularity in management of femoral nonunion with few reports in tibial nonunion. The aim of the current study is to present our results in augmentation plate in management of tibial nonunion with intramedullary nail. <i>Patient and methods:</i> From 2017 till 2021, 20 cases of nonunited tibial fractures fixed by IM nails was included. Augmentation plate without removing the nail in addition of autogenous iliac graft. <i>Results:</i> Union was obtained in all the cases (20 cases) in an average time of about 6.22 months (range 3-12 months). Complications are few included 3 casea of superficial infection and parasthesia at iliac graft site. <i>Conclusion:</i> Plate augmentation without removal of IM nail is a good option in management of aseptic nonunion tibia with excellent results and few complications.

Mid-Term Results of Total Hip Arthroplasty for Femoral Neck Nonunions in Long-Term Hemodialysis Patients

Background. Performing primary arthroplasty in patient with renal osteodystrophy is associated with a number of difficulties due to low bone mineral density, which complicates the fixation of the endoprosthesis components, the presence of bone defects, and functional insufficiency of the gluteal muscles. The aim of the study evaluation of the mid-term results of primary total hip arthroplasty using cemented femoral and acetabular implants in hemodialysis patients with nonunions of the femoral neck. Materials and Methods. The authors conducted a study of 26 hemodialysis patients with pseudarthrosis of the femoral neck. The patients were divided into 3 groups: group I (12 patients) classification type A of the femoral neck nonunion, group II (10 patients) classification type B, group III (4 patients) of type C who underwent total hip arthroplasty. Results. The longest surgery duration was observed in patients of the III study group 121.2519.26 minutes. There were no statistically significant differences between the patients of the II and III study groups. The smallest rate of intraoperative blood loss was noted among patients of the 1st study group 440.83133.65 ml, the statistical significance of the differences was obtained both between the 1st and II, and between the I and III study groups, respectively. The smallest total number of complications after surgery was obtained in the 1st group 4 (8.33%). Revisions were performed in 8 (30.7%) patients among all three groups. There was a significant improvement on the Oxford hip score after 12 months (mean 29.8) and 24 months (mean 33.1) in all groups compared with preoperative results (mean 12.5). Twelve 12 months after surgery, the average value of the pain severity was reduced by 72.6% and amounted to 2.01. The risk of getting any orthopedic complication in cemented total hip arthroplasty of the classification type A of the pseudarthrosis is 2.5, with type B 3.4, with type C 5.7. Conclusion. The classification of femoral neck nonunions in hemodialysis patients allows to determine the tactics of surgical treatment. Cemented dual mobility cups are effective in patients with any type of femoral neck nonunions.

Risk Factors for Development of a Recalcitrant Femoral Nonunion: A Single Surgeon Experience in 122 Patients.

The goals of the study were (1) to document the healing rates of femoral nonunions stratified by those that healed as intended, healed after a subsequent intervention, and those that did not heal; (2) to report the prevalence of recalcitrant femoral nonunions and (3) to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion. Longitudinal observational cohort study. Academic Level 1 trauma center. One hundred twenty-two femoral nonunions treated with either a plate or intramedullary nail by a single surgeon between 1991 and 2018. Bivariate and multivariate regression analysis were performed to identify specific demographic, injury, and treatment factors in patients who developed a recalcitrant nonunion. Although 83.6% of the femoral nonunions eventually healed, only 66% "healed as intended" with 17.2% requiring 1 or more additional procedures to consolidate and 16.4% of nonunions failing to unite. There were no statistically significant differences in the recalcitrance rate when we compared treatment with conventional versus locked plates or primary versus exchange nailing. Risk factors for developing a recalcitrant nonunion were deep infection, current smokers, metabolic bone disease, and patients who had undergone 3 or more prior surgical procedures. The use of both intramedullary nails and modern plates were associated with a high rate of recalcitrance. Infection, current smokers, metabolic bone disease, and 3 or more prior surgical procedures were predictors for the development of a recalcitrant nonunion. Therapeutic Leve IV. See Instructions for Authors for a complete description of levels of evidence.

Use of the 95-degree angled blade plate with biological and mechanical augmentation to treat proximal femur non-unions: a case series

BackgroundIntertrochanteric and subtrochanteric non-union are rare but challenging complications. In the present study, we investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions.MethodsBetween October 2015 and February 2021, a retrospective cohort study was conducted at our institution to investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions, following the mechanical failure of the first device. All the patients underwent a clinical and radiographic follow-up at 6 weeks, 3, 6, 9, 12 and 18 months; at each follow-up, a plain radiograph of the femur was performed and patients were assessed using Harris Hip Score (HHS) and the Short Form-12 (SF-12) questionnaire.ResultsFrom October 2015 and February 2021, 40 proximal femur non-unions were managed at our Institution. Fifteen patients out of forty (37.5%) met the inclusion criteria. The main data of the study are summarized in Table 1; patients’ mean was 57 years old (range 19–83); 10 males and 5 females were included in the study. All the patients completely healed clinically and radiologically at an average of 6.1 months (range 4–13). All these patients returned to their pre-injury mobility status. During an average follow-up period of 25 months (range 8–60), the observed complications included wound dehiscence, which was treated with a superficial surgical debridement, a below-the-knee deep vein thrombosis, and a blade plate failure 3 months after the first revision surgery.ConclusionsThis study shows the treatment of inter-and sub-trochanteric non-unions with a 95° blade plate, medial strut allograft, and bone autograft obtained with RIA system, together with a varus malalignment correction, leads to a high percentage of bone healing, with a low incidence of complications and good clinical outcome.

“Use of pedicled corticoperiosteal flap in resistant cases of distal femur non-union: Our learning experience”

Nonunion of distal femur is a complex problem with the added burden of poor bone stock, osteopenia, and joint contracture. Various procedures are described ranging from osteosynthesis using auto/allograft, to use of mega prosthesis. Use of vascularized corticoperiosteal flap based on descending genicular artery and superomedial genicular artery is a new technique to provide living vascular graft for the nonunion site. Although few free corticoperiosteal flap reconstructions have been reported in the past for these distal femur nonunions, this flap has seldom been used as a pedicled variety. Through this article, we aimed at highlighting the main obstacles faced while using pedicled corticoperiosteal flap for these patients given its dearth in literature. Five patients of at least two previously failed osteosynthesis for distal femur fracture non-union were selected for performing corticoperiosteal flaps. The intraoperative findings that were both favourable and unfavourable were documented along with the outcome of procedure in the form of callus formation or fracture healing. Dissection of the flap was more tedious in these cases than when performed for a different indication in a virgin territory. However, despite the previous trauma resulting in decreased pliability of their vessels, all flaps were viable at the end of procedure with favourable cosmetic and functional outcomes. Despite the complexities in flap harvest, use of the less morbid and technically easier "Pedicled corticoperiosteal flap" and osteosynthesis along with the auto technique is a worthwhile option for retaining the native joint with favourable outcome in non-unions of distal femur.

Comparison of single versus double tranexamic acid dose regimens in reducing post-operative blood loss following intramedullary nailing of femoral fracture nonunions.

Tranexamic acid has been found to be effective in reducing peri-operative blood loss and is widely used across surgical specialties including orthopaedic surgery. However, there is still no consensus on the most appropriate and effective dose regimen. This study therefore compared the efficacy of single versus double dose regimens in patients that had interlocking intramedullary nailing by assessing the volume of drain output with the objective of determining the more effective regimen. The study was a multicenter prospective study amongst adult patients who had interlocking intramedullary nailing for femoral nonunions. Following ethical approval, consent was obtained from eligible patients who were randomly assigned into two study groups. Group A patients had single pre-incision tranexamic acid bolus of one gram while group B patients had a second (repeat) one gram bolus (at the completion of wound closure). The volume of drain output at 48h postop was the primary outcome measure and data collection was via an online data collection form linked to the google drive of the principal investigator. The mean of the drain output of the two groups was compared for statistical significance. A total of 61 patients participated in the study with 30 patients in group A and 31 patients in group B. The demographic data and duration of fracture were comparable in the two groups. Group A had a mean drain volume of 274.80ml (± 103.93ml) while group B had a mean of 187.94ml (± 41.95ml) and the difference was found to be statistically significant. (P, 0.000). The findings suggest that double dose perioperative tranexamic acid regimen is superior to single-dose peri-operative tranexamic acid regimen in reducing post-operative blood loss in patients undergoing interlocking intramedullary nailing for femoral nonunions.

Nomogram for predicting reoperation following internal fixation of nondisplaced femoral neck fractures in elderly patients

ObjectiveWe aimed to evaluate risk factors and develop a nomogram for reoperation after internal fixation of nondisplaced femoral neck fractures (FNFs) in elderly patients.MethodsWe conducted a retrospective study involving a total of 255 elderly patients who underwent closed reduction and internal fixation with cannulated screw system for nondisplaced FNFs between January 2016 and January 2019. We collected data on demographics, preoperative radiological parameters, surgery, serum biochemical markers, and postoperative rehabilitation. In addition, we performed univariate and multivariate logistic regression analyses to determine independent risk factors for reoperation, and then developed a nomogram to assess the risks of reoperation. Besides, discriminative ability, calibration, and clinical usefulness of the nomogram were evaluated using the concordance index (C-index), the receiver operating characteristic (ROC) curve, calibration curve and decision curve analysis (DCA), respectively. We employed bootstrap method to validate the performance of the developed nomogram.ResultsOur analysis showed that among the 255 patients, 28 (11.0%) underwent reoperation due to osteonecrosis of the femoral head (14 cases), mechanical failure (8 cases) or nonunion (6 cases). All of the 28 patients underwent conversion surgery to arthroplasty. The multivariate logistic regression analysis demonstrated that preoperative posterior tilt angle ≥ 20°, Pauwel’s III type, younger patients, preoperative elevated levels of alkaline phosphatase (ALP), preoperative hypoalbuminemia, and early postoperative weight-bearing were independent risk factors for reoperation. In addition, the C-index and the bootstrap value of the developed nomogram was 0.850 (95% CI = 0.803–0.913) and 0.811, respectively. Besides, the calibration curve showed good consistency between the actual diagnosed reoperation and the predicted probability, while the DCA indicated that the nomogram was clinically valuable.ConclusionsOur analysis showed we successfully developed and validated a nomogram for personalized prediction of reoperation after internal fixation of nondisplaced FNFs in elderly patients. This model would help in individualized evaluation of the need for reoperation and inform strategies aimed at eliminating the need for the reoperation.

English

BACKGROUND Infected non-union is a complex, debilitating and challenging disorder affecting orthopaedic surgeon and patient in terms of cost and time.1 Antibiotic impregnated nail has been a cheap and effective method used for treatment of infected nonunion. Factors that may lead to infected non-union are many.2,3 High local concentrations of antibiotics with minimal systemic levels and without systemic side effects make local antibiotic therapy a very useful technique in treating infected non-union. 4 Buchholz and Engelbrecht were the first to use antibiotic impregnated cement.5 Major advantage of using antibiotic impregnated cement is, it provides high concentration of antibiotics locally with less systemic side effects.6 The purpose of this study was to determine the functional outcome of antibiotic impregnated nail in treatment of infected non-union of femur and tibia. Antibiotic cement impregnated intra-medullary nail can provide stability, help in control of infection,7 is easy to remove, and also provides all the advantages of the cement beads.8,9 METHODS This prospective study was done on 25 cases at Government Medical College Thrissur from 01 September 2016 to 01 April 2018. Functional results were evaluated with regard to control of infection, bony union, deformity, limb leg discrepancy and complications (both intra and post-operative complications). RESULTS Most of the cases had type 2 open injury initially, accounting for 49 %. Staphylococcus aureus was reported in 56 % of cases. Infection control was achieved in 23 cases. Bony union was visualised in 18 cases, remaining 5 cases united following bone grafting. In 2 cases there was no control of infection and no bony union was achieved, later antibiotic nail removal and Ilizarov fixation was planned. Bone grafting was done in 10 cases. CONCLUSIONS Antibiotic impregnated cement nailing is a simple, economical and very effective procedure with less complication and shorter duration of treatment when compared with other conventional procedures. KEYWORDS Infected Non-Union, Long Bones, Antibiotic Impregnated Cement Nail

Clinical observation and finite element analysis of cannulated screw internal fixation in the treatment of femoral neck fracture based on different reduction quality

ObjectiveFemoral neck fracture is one of the most common bone types. The effect of reduction quality on hip joint function and complications after screw internal fixation is not fully understood. To investigate the clinical efficacy and mechanical mechanism of positive buttress, anatomical reduction, and negative buttress in the treatment of femoral neck fracture after cannulated screw fixation.MethodsRetrospective analysis of patients with femoral neck fracture treated with three cannulated screws internal fixation in our hospital from January 2013 to December 2018. According to the quality of fracture reduction, the patients were divided into positive buttress group, anatomical reduction group, and negative buttress group. Basic information such as injury mechanism, time from injury to surgery, Garden classification and Pauwels classification was collected, Harris scores were performed at 3 months, 6 months, and 12 months after surgery, and postoperative complications (femoral head necrosis, femoral neck shortening, and femoral neck nonunion) were collected. At the same time, three groups of finite element models with different reduction quality were established for stress analysis, their stress clouds were observed and the average displacement and stress of the three groups of models were compared. P < 0.05 was used to represent a statistically significant difference.ResultsA total of 225 cases of unilateral femoral neck fractures were included and followed up for an average of 4.12 ± 0.69 years. There was no significant difference in age, gender, side, injury mechanism, time from injury to surgery, BMI, Garden classification, Pauwels classification, and follow-up time among the three groups (P > 0.05). However, there was significant difference in Harris score at 6 and 12 months after operation among the three groups (P < 0.05), which was higher in the positive buttress group and anatomical reduction group than in the negative buttress group. In addition, the incidence of osteonecrosis of the femoral head in the negative buttress group (32.2%) was greater than that in the anatomical reduction group (13.4%) and the positive buttress group (5.4%) (P < 0.05). In addition, the incidence of femoral neck nonunion and femoral neck shortening in the negative buttress group was also higher than that in the anatomical reduction positive buttress group (P < 0.05). The finite element results showed that the stress and fracture end displacement in the negative buttress group were greater than those in the positive buttress group (P < 0.05).ConclusionBoth positive buttress and anatomical reduction in the treatment of femoral neck fracture with cannulated screw internal fixation can obtain better clinical effect and lower postoperative complications. Positive brace support and anatomic reduction can limit the restoration of femoral stress conduction. Therefore, it is not necessary to pursue anatomical reduction too deliberately during surgery, while negative buttress reduction should be avoided.

A study on the management of non-union of fracture distal femur with locking plates

Background: US FDA defines non-union as fracture bone that has not completely healed in 9 months since injury and which has not shown any signs of healing over 3 consecutive months on serial x-rays. The operative treatment depends on the type of non-union. There are one-step or two-step procedures according to the principles of the ‘diamond concept’. This involves the improvement of the mechanical situation (in most cases with a re osteosynthesis) and vascularization, local application of osteoconductive carriers e.g. tricalcium phosphate, vial cells from autologous bone and osteoinductive substances like bone morphogenic proteins (BMP-2 or BMP-7). Aim: To study the principles and method of fixation of non-union of distal femur with lock plates. Material and Methods: It was a prospective study including patients with non-union of distal femur admitted and examined according to protocol after obtaining informed consent from the patient and permission from the institutional ethics committee. 40 cases satisfying the inclusion criteria admitted in tertiary healthcare centre of Navi Mumbai since May 2018 to March 2020 with minimum 1 year of follow up were included in the study.Results: Patients were also evaluated as per non-union scores. The average non-union score was 19 (range 11 to 27). All of the non-unions united, at an average of 19 weeks. The average arc of knee motion improved from 85° preoperatively to 114° postoperatively. The average Neer’s score improved from an average of 60.4 points (range 16 to 44 points) preoperatively to 89 points post operatively. The knee society score (Part 1) improved from an average of 51.87 points (range 36 to 68) preoperatively to 81.725 points (range 74 to 93) post-operatively. Conclusion: The operative technique respecting the biology and biomechanical principles has shown the influence of success of treating these fractures with locking plates.