Fixation Of Femoral Shaft Fractures Research Articles

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 Methodical Approach to Treatment Following Failed Internal Fixation of Ipsilateral Femoral Neck and Shaft Fractures

A Methodical Approach to Treatment Following Failed Internal Fixation of Ipsilateral Femoral Neck and Shaft Fractures

Flexible Intramedullary Nail Versus Submuscular Locked Plate with the Cluster Technique in Pediatric Femoral Shaft Fractures Fixation.

The aim of this study is the comparison between the flexible intramedullary nail and submuscular Locked Plate with the cluster technique in fixation of pediatric femoral shaft fractures at the age group between 6 and 12years old with simple diaphyseal closed or Gustilo open grade I fractures. Fifty children aged 6-12years with femoral fractures were enrolled in this study. The children were randomly assigned equally to the two groups for fractures fixation. The follow-up period was 1year. A comparison of various parameters and outcomes between both groups was documented. No significant differences were detected between both groups regarding the age, gender, affected side, mechanisms of fracture, or fracture classifications. The operative time and radiation time were longer in the plating group, while the amount of blood loss was lesser in the nail group. The patients treated with plating had better results concerning knee range of motion, weight-bearing, malalignment, and length discrepancy, with fewer complications and better functional outcomes. The result of the present study supports the use of submuscular locked plate with cluster technique in the treatment of studied fractures over flexible IMN.

Minimally Invasive Internal Fixation of Femoral Shaft Fractures-A Biomechanical Study with a Disruptive Technique.

(1) Background: In polytrauma patients, femur fractures are usually stabilised by external fixation for damage control, later being treated with definitive plate or nail osteosynthesis. Screw/rod systems established in spinal surgery might be inserted for internal fixation, providing sufficient fracture stability that subsequent intervention is unnecessary. This was to be investigated biomechanically. (2) Methods: The unilaterally applied spinal internal fixator (IF) was subjected to load and deformation analysis on artificial femurs with 32-A3 fracture according to AO classification. Distance of screws to fracture and rod to cortical bone were analysed as parameters influenced surgically as stiffness and deformation of the treated fracture. In addition, the stability of another construct with a second screw/rod system was determined. The axial load in stance phase during walking was simulated. The results were compared against an established fixed-angle plate osteosynthesis (IP). (3) Results: There were no implant failures in the form of fractures, avulsions or deformations. All unilateral IF combinations were inferior to IP in terms of stability and stiffness. The bilateral construct with two screw/rod systems achieved biomechanical properties comparable to IP. 4) Conclusion: Biomechanically, a biplanar screw/rod system is suitable for definitive fracture stabilisation of the femur, despite a damage control approach.

Hip fractures following intramedullary nailing fixation for femoral fractures

IntroductionProximal peri-implant femoral fractures occur following intramedullary nailing (IMN) fixation for trochanteric, femoral shaft, and distal femoral fractures. However, analyses of secondary hip fractures (SHFs) using large clinical samples are lacking. Therefore, we aimed to report the incidence and clinical outcomes of SHF after nailing fixation (IMN or cephalomedullary nailing [CMN]) for overall femoral fractures. In addition, we focused on IMN for femoral shaft fractures and investigated the risk factors for SHF. MethodsThis multicenter, retrospective, cohort study included 2,293 patients aged > 60 years who underwent nailing fixation for femoral fractures. The primary outcome was the incidence of SHF. In the assessment of clinical outcomes, we evaluated reoperation and the regaining of walking ability following SHF management. In addition, we conducted multivariable logistic regression analyses to examine the association between risk factors and SHF. ResultsSeventeen (0.7%) patients had SHFs, including 12 femoral neck fractures and 5 trochanteric fractures. Antegrade IMN was the most common type of nailing fixation. Multivariable analysis demonstrated that the absence of femoral head fixation was significantly associated with the incidence of SHF following IMN for femoral shaft fractures (odds ratio, 17.0; 95% confidence interval, 1.9–2265.7; p=0.006). In the assessment of clinical outcomes, there were two reoperations (16.7%) in the secondary femoral neck fracture group. Patients with secondary trochanteric fractures tended to have a lower probability of regaining walking ability than those with secondary femoral neck fractures (20% vs. 50%). ConclusionsIn this multicenter study, the incidence of SHF after nail fixation for femoral fractures was 0.7%. The absence of femoral head fixation was significantly associated with SHF, and the clinical outcomes were poor. Therefore, femoral head fixation at the initial IMN fixation for femoral fractures may be a fixation option for surgeons to consider as an SHF prevention measure.

Radiographic outcomes of femur fractures following SIGN Fin nailing in low- and middle-income countries.

Objective:To measure the effectiveness of the Surgical Implant Generation Network (SIGN) Fin nail for achieving satisfactory postoperative radiographic alignment following femoral shaft fractures.Methods:Femoral shaft fractures stabilized with the SIGN Fin nail were identified using the SIGN Online Surgical Database. A random number generator was used to identify 500 femur fractures fixed within 6 weeks of injury for which postoperative radiographs were available. Fractures were classified using OTA/AO and Winquist-Hansen classification systems. Deviation from anatomic alignment was measured on anterior-posterior and lateral radiographs using an on-screen protractor tool. Other clinical variables recorded in the SIGN Online Surgical Database were also analyzed. Simple logistic regression was used to assess for associations between subject and surgical characteristics and misalignment status. Intra- and inter-rater agreement was assessed with intraclass correlation coefficient (ICC).Results:The overall rate of malalignment >5° was 9.4%. Factors associated with increased incidence of malalignment include older age, increased time to surgery, distal diaphyseal location, closed (vs open) reduction, degree of comminution, and fracture classification. Intra-rater ICC was 0.70 (0.52, 0.82) in the coronal plane and 0.55 (0.32, 0.72) in the sagittal plane. Inter-rater ICC was 0.37 (0.08, 0.60) and 0.32 (0.05, 0.54), respectively.Conclusion:The SIGN Fin nail is an effective implant for fixation of femoral shaft fractures in resource-limited regions, achieving rates of satisfactory postoperative alignment comparable to that of the standard SIGN nail as well as femoral shaft fractures treated in North American Trauma Centers. Further research is required to investigate rotational alignment and long-term clinical outcomes for the SIGN Fin nail.Level of evidence:IV.

Single-Stage Versus 2-Stage Bilateral Intramedullary Nail Fixation in Patients With Bilateral Femur Fractures: A Multicenter Retrospective Review.

To evaluate rates of complications in patients with bilateral femur fractures treated with intramedullary nailing (IMN) during either 1 single procedure or 2 separate procedures. A multicenter retrospective review of patients sustaining bilateral femur fractures, treated with IMN in single or 2-stage procedure, from 1998 to 2018 was performed at 10 Level-1 trauma centers. Ten Level-1 trauma centers. Two hundred forty-six patients with bilateral femur fractures. Intramedullary nailing. Incidence of complications. A total of 246 patients were included, with 188 single-stage and 58 two-stage patients. Gender, age, injury severity score, abbreviated injury score, secondary injuries, Glasgow coma scale, and proportion of open fractures were similar between both groups. Acute respiratory distress syndrome (ARDS) occurred at higher rates in the 2-stage group (13.8% vs. 5.9%; P value = 0.05). When further adjusted for age, gender, injury severity score, abbreviated injury score, Glasgow coma scale, and admission lactate, the single-stage group had a 78% reduced risk for ARDS. In-hospital mortality was higher in the single-stage cohort (2.7% compared with 0%), although this did not meet statistical significance (P = 0.22). This is the largest multicenter study to date evaluating the outcomes between single- and 2-stage IMN fixation for bilateral femoral shaft fractures. Single-stage bilateral femur IMN may decrease rates of ARDS in polytrauma patients who are able to undergo simultaneous definitive fixation. However, a future prospective study with standardized protocols in place will be required to discern whether single- versus 2-stage fixation has an effect on mortality and to identify those individuals at risk. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Complications after intramedullary nail fixation of pathological versus non-pathological femoral shaft fractures: a retrospective cohort study in 233 patients

BackgroundPostoperative adverse events after intramedullary nailing have been reported in patients with metastatic pathological and non-pathological femoral fractures. Other consequences to be considered are readmission and reoperation. Few studies have compared the risks of postoperative adverse events, reoperation, and readmission after intramedullary nailing of pathological and non-pathological femur fractures. This study was designed to test the hypothesis that patients with pathological femoral fractures had more adverse events, readmission, and reoperation following surgical fixation than non-pathological femoral fractures.MethodsThis was a retrospective observational cohort study, conducted at an academic medical center in Thailand. The data from patients with femoral shaft fractures undergoing long intramedullary nailing, from June 1, 2006, to June 30, 2020, were included. Patients who had a pathological fracture from a primary bone tumor, metabolic bone disease, or inadequate/missing information were excluded. Patients with pathological fractures from metastatic bone disease were assigned to be the pathological group whereas those with traumatic fractures were assigned to be the non-pathological group. The primary outcome was the risk of inpatient adverse events as compared between the two groups. The secondary outcome was the risk of consequences after discharge as compared between the two groups. Outcomes were analyzed by using multivariate logistic regression analysis.ResultsThe total number of patients was 48 in the pathological fracture group and 185 in the non-pathological group. There were significantly higher rates of surgical and medical adverse events in patients with pathological fractures compared to patients with non-pathological fractures. After adjusting for potential confounding factors in multivariate regression analysis, patients with pathological fractures had higher odds of both adverse surgical (adjusted OR 2.43, 95 % CI 1.15–5.13) and medical adverse events (adjusted OR 2.81, 95 % CI 1.13–7.03).ConclusionsPatients with metastatic pathological femoral shaft fractures undergoing intramedullary nailing were more likely to experience postoperative adverse events than patients with non-pathological fractures.

Comparison of Open and Closed Nailing for Femoral Shaft Fractures: A Retrospective Analysis.

IntroductionOpen and closed nailing are the two reduction methods used for the fixation of femoral shaft fractures. The study aims to assess the clinical and functional outcomes of open and closed nailing for closed femoral shaft fractures.MethodologyA total of 398 patients who underwent intramedullary nailing fixation of nonpathological femoral shaft fracture between January 2016 to December 2019 were reviewed retrospectively. Two hundred seventy-four underwent closed nailing, and 124 were considered for open nailing.ResultsThe primary outcome reviewed was the union rate of fracture. Other outcomes analyzed were complications, intraoperative blood loss, time to union, and the duration of the procedure. Patients in the open group had a union of fracture in 15.71 weeks, closed nailing group had a union in 15.53 weeks (p-value 0.495). Patients with open nailing had a mean Radiological union scale in tibial (RUST) fracture score of 11.435, whereas the closed nailing group had a mean of 11.664 (p-value 0.187). Operative time was higher in the open group when compared to the closed nailing group (p-value 0.000). However, intraoperative blood loss was more in open nailing in comparison to closed nailing. Furthermore, 15 patients with closed nailing had non-union, whereas 11 had non-union after open nailing (p-0.204). Superficial infection and deep infection requiring debridement were equally observed among the two treatment groups.ConclusionFixation of femoral shaft fractures with open nailing has similar outcomes in union rates, time to union, and rates of significant complication similar to those of close nailing.

Effectiveness of orthopedic implant removal surgery in patients with no implant-related symptoms after fracture union of isolated lower extremity shaft fractures: patient-centered evaluation.

Routine orthopedic implant removal surgery (OIRS) in patients with no implant-related symptoms after union is controversial. Various factors, such as various fracture sites, fracture types, and accompanying fractures at other sites, act as error variables in the evaluation of routine OIRS. The purpose of this study is to evaluate the benefits of orthopedic implant removal surgery (OIRS) in patients with no implant-related symptoms such as infection and soft tissue irritation after union of isolated lower extremity shaft fractures from a patient-centered evaluation MATERIALS AND METHODS: Eighty-four patients who achieved fracture union after internal fixation of femoral shaft or tibial shaft fractures (March 2004 to December 2018) and who showed no implant-related symptoms were evaluated retrospectively. Minimum post-OIRS follow-up period was 1 year. Thirty-eight patients were treated with intramedullary nail and 13 were treated with plate and screws for femoral shaft fracture. Twenty patients were treated with intramedullary nail and 13 were treated with plate and screws for tibial shaft fracture. All patients subsequently underwent OIRS. Quality of life (QoL) and lower extremity pain using visual analogue scale (VAS) were evaluated 1 day before OIRS. Patient satisfaction with the OIRS, VAS, and QoL were assessed at least 1 year after OIRS using the SF-36 questionnaire. The physical component score, mental component score, and scores of all eight domains showed significant improvement after OIRS (p < 0.01). Patients with femoral shaft fractures tended to have lower pre- and post-OIRS SF-36 scores than those with tibial shaft fracture. Among patients with femoral shaft fracture, SF-36 scores were comparable in the nail and plate groups. Among patients with tibial shaft fracture, nail group showed relatively better QoL than the plate group, before and after OIRS in spite of several complications such as formation of scar tissue, nerve damage, and refracture. Patients with no implant-related symptoms showed significant improvement in QoL and satisfaction after OIRS. This suggests that OIRS is beneficial from the patients' evaluation. Therapeutic Level II.

Comparison of standard versus reconstruction proximal interlocking screw configurations for antegrade intramedullary nail fixation of femoral shaft fractures

BackgroundThe standard proximal interlocking screw (SS) configuration for antegrade intramedullary nail (IMN) fixation of femoral shaft fractures is lateral to medial or from the greater to less trochanter. Some authors argue for the routine use of the reconstruction screw (RS) configuration (oriented up the femoral neck) instead to prevent femoral neck complications. The purpose of this study was to compare a matched cohort of patients receiving these screw configurations and subsequent complications. MethodsA retrospective review of two urban level-one trauma centers identified adults with isolated femoral shaft fractures undergoing antegrade IMN. Patients with RS and SS configurations were matched 1:1 by age, sex, fracture location, and AO classification in order to compare complications. Results130 patients with femoral shaft fractures were identified. SS and RS configurations were used in 83 (64%) and 47 (36%) patients. 30 patients from each group were able to be matched for analysis. The RS and SS group did not differ in age, fracture location, AO classification, operative time, or number of distal interlocking screws. The RS group had fewer open fractures and were more likely to have two proximal screws. There were 7 complications, including 5 nonunions and 2 delayed unions, with no detectable difference between RS vs. SS groups (10% vs 13%, Proportional difference −3%, 95% confidence interval (CI) −30 to 14%, p = 0.1). There were no femoral neck complications in the entire cohort of 130 patients. On multivariate analysis none of the variables analyzed were independently associated with the development of complications. ConclusionsIn this matched cohort of patients with femoral shaft fractures undergoing antegrade IMN fixation, RS and SS configurations were associated with a similar number of complications and no femoral neck complications. The SS configuration remains the standard for antegrade IMN femoral shaft fixation. Level of evidenceLevel III, Retrospective cohort study.

"Ratio of fracture site diameter to isthmus femoral canal diameter" as a predictor of complication following treatment of infra-isthmal femoral shaft fracture with antegrade intramedullary nailing.

Fixation of infra-isthmus femoral shaft fracture using antegrade intramedullary (IM) nailing is difficult and is associated with a high complication rate. This study aimed to identify risk factors for complications following this procedure. The ratio of the fracture site diameter to the diameter of the femoral intramedullary canal of the isthmus (FI ratio) was evaluated as a novel parameter to predict complication. Patients who underwent antegrade IM nailing for infra-isthmus femoral shaft fracture between January 2008 and December 2018 and had a minimum of 12 months of follow-up were retrospectively reviewed. The primary outcome was occurrence of complication, including non-union, mal-alignment, fixation failure, or progressive loss of reduction. Logistic regression analysis was performed to identify risk factors of complication. The sensitivity and specificity of FI ratio as a predictor of complication was calculated. A receiver operating characteristic (ROC) curve was generated to establish an FI ratio threshold to predict occurrence of complication following antegrade IM nailing. Sixty-five patients with a mean age of 47.1 years were included. Using univariate logistic regression analysis, comminuted fracture pattern (p=0.026), distance from screws to fracture site (< 3cm) (p=0.002), and higher FI ratio (p=0.001) were associated with complication. Using multivariate logistic regression analysis, FI ratio was identified as an independent risk factor for complication following antegrade IM nailing (p=0.038). ROC curve indicated that FI ratio ≥ 2 had sensitivity and specificity of 0.72 and 0.72, respectively, in predicting complication. Our study indicates that wider intramedullary diameter at the fracture site was associated with higher complication rate following antegrade IM nailing in distal infra-isthmal femoral fractures. The FI ratio could be a reliable predictor of complication after antegrade IM nailing for such fracture, and alternative strategies should be considered for patients with higher FI ratio (≥ 2).

Effects of exercise training on bone mineral density and some health-related outcomes in HIV conditions: A randomized controlled trial.

Introduction:Human Immunodeficiency Virus (HIV) infection remains prevalent co-morbidity, and among fracture patients. Few studies have investigated the role of exercise interventions in preventing bone demineralization in people who have fractures and HIV. If exercise exposed, HIV-infected individuals may experience improved bone health outcomes (BMD), function, quality of life (QoL). The study will aim to assess the impact of home based exercises on bone mineral density, functional capacity, QoL, and some serological markers of health in HIV infection among Nigerians and South Africans.Methods and design:The study is an assessor-blinded randomized controlled trial. Patients managed with internal and external fixation for femoral shaft fracture at the study sites will be recruited to participate in the study. The participants will be recruited 2 weeks post-discharge at the follow-up clinic with the orthopaedic surgeon. The study population will consist of all persons with femoral fracture and HIV-positive and negative (HIV-positive medically confirmed) aged 18 to 60 years attending the above-named health facilities. For the HIV-positive participants, a documented positive HIV result, as well as a history of being followed-up at the HIV treatment and care center. A developed home based exercise programme will be implemented in the experimental group while the control group continues with the usual rehabilitation programme. The primary outcome measures will be function, gait, bone mineral density, physical activity, and QoL.Discussion:The proposed trial will compare the effect of a home-based physical exercise-training programme in the management of femoral fracture to the usual physiotherapy management programmes with specific outcomes of bone mineral density, function, and inflammatory markers.Trial registration:The study was prospectively registered with the Pan African Clinical Trials Registry (Reference number – PACTR201910562118957) on October 21, 2019. (https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9425).

Safety and efficacy of a novel cephalomedullary nail in femoral shaft fractures: a retrospective observational cohort in 33 patients

BackgroundDespite advances in femoral shaft fracture fixation, the nonunion rate remains relatively high; and there is limited data on the efficacy and failure rate of specific implants. A novel cephalomedullary nail provides the ability to treat femur shaft fractures in isolation, with associated ipsilateral femur injuries, and provides various options for proximal and distal fixation exists on the market; but literature remains limited on the safety and efficacy of this implant. The aim of this study is to evaluate the early failure rate of this cephalomedullary nail, while comparing the nonunion rate to what is currently presented in the literature. This study is the first of its kind in evaluation of a specific implant for treatment of femoral shaft fractures and ipsilateral pathology.MethodsPatients over 18 years of age, with traumatic femur shaft fractures, treated with this particular cephalomedullary nail and available for a minimum of 3-month follow-up were included for analysis. Data was collected by retrospective chart review and review of existing radiographs. Demographic data, injury details, AO/OTA fracture classification, and implant details were recorded for each patient. Primary outcome measured was implant failures (screw or nail breakage). Secondary outcomes measured included malunion, nonunion, deep infection, post-operative complications, and need for reoperation.ResultsOf the 33 patients included for analysis, 1 patient went on to non-union. There were no cases of implant failure. The single nonunion was a high-energy mechanism, open fracture, and higher level AO/OTA classification. The remaining 32 reached radiographic union at 3 months.ConclusionThe nonunion rate of this novel cephalomedullary nail is comparable to what is reported in the literature. This nail is a safe and effective implant to treat femoral shaft fractures with a variety of ipsilateral femoral shaft injuries and reliably leads fracture union. Further studies are needed analyzing implant failure and comparing specific implants.

Quantitative Evaluation of Embolic Load in Femoral and Tibial Shaft Fractures Treated With Reamed Intramedullary Fixation.

To compare the volume of embolic load during intramedullary fixation of femoral and tibial shaft fractures. Our hypothesis was that tibial intramedullary nails (IMNs) would be associated with less volume of intravasation of marrow than IM nailing of femur fractures. Prospective observational study. Urban Level I trauma center. Twenty-three patients consented for the study: 14 with femoral shaft fractures and 9 with tibial shaft fractures. All patients underwent continuous transesophageal echocardiography, and volume of embolic load was evaluated during 5 distinct stages: postinduction, initial guide wire, reaming (REAM), nail insertion, and postoperative. Volume of embolic load was measured based on previously described luminosity scores. The embolic load based on fracture location and procedure stage was evaluated using a mixed effects model. The IMN procedure increased the embolic load by 215% (-12% to 442%, P = 0.07) in femur patients relative to tibia patients after adjusting for baseline levels. Of the 5 steps measured, REAM was associated with the greatest increase in embolic load relative to the guide wire placement and controlling for fracture location (421%, 95% confidence interval: 169%-673%, P < 0.01). Femoral shaft IMN fixation was associated with a 215% increase in embolic load in comparison with tibial shaft IMN fixation, with the greatest quantitative load during the REAM stage; however, both procedures produce embolic load. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Anteroposterior view of the knee does not reliably replace the lateral view during evaluation of femoral torsion: a case series

Background: Restoration of anatomic torsion is a critical step in operative fixation of femoral shaft fractures. Several accepted methods use the morphology of the femur to determine torsion. The anteroposterior view of the knee has been used to simplify the procedure, yet this method has not been validated. The purpose of this study was to evaluate native distal femoral and patellar anatomy to compare the reliability of using the anteroposterior view, which includes landmarks outside of the femur, to using the lateral view, which uses only femoral morphology, for establishing appropriate torsion in femoral shaft fractures. Methods: Fifteen patients without a history of lower extremity fractures participated. Each participant had anteroposterior and lateral images taken of their femurs. Data were compared between repetitions of a single limb, two legs of a single patients, and between patients. Intrarater and interrater reliability were measured. Results: Side-to-side variability in the relative position of the patella to the femur was identified on anteroposterior imaging, with up to 14-degree difference between limbs noted. Overall, strong intraclass reliability and reproducibility of the measurements was achieved. Conclusions: The use of anteroposterior imaging alone does not reliably replace the lateral view for evaluation of femoral torsion. Circumstances of erroneous results when using the anteroposterior view were identified. Due to side-to-side differences, the anteroposterior technique cannot be recommended to determine anatomic torsion in femoral shaft fractures. The conventional technique using overlapping posterior condyles on the lateral view of the knee remains an important part of determining femoral torsion. Level of Evidence: Level IV.

“Reverse miss-a-nail technique” of reconstruction nailing for successful fixation of the ipsilateral femoral neck and shaft fracture

Although reconstruction nails have an advantage of single-construct fixation in ipsilateral femoral neck and shaft fractures, they have not been used widely due to the technical challenges associated with their placement. Reduction is particularly demanding in patients with displaced neck fractures after nailing of the shaft fracture, and can be resulted in nonunion, malunion, and osteonecrosis. We report a new technique of reconstruction nailing after the provisional reduction and fixation of a neck fracture to achieve successful healing of this injury. Osteosynthesis using a reconstruction nail was performed in ten consecutive patients with displaced femoral neck and shaft fracture. After closed reduction of the displaced neck fracture, the femoral neck was provisionally fixed with pins in an anterolateral-to-medial direction. While maintaining reduction of the neck fracture, a nail was inserted and passed into the medullary canal posterior to the provisionally fixed pins with indirect reduction of the shaft fracture. After two reconstruction locking screws were fixed for proximal interlocking, the provisional pins were removed once distal interlocking was achieved. The radiologic outcomes included quality of reduction, healing rate, and time to the union were appraised, and the functional outcomes were assessed with Friedman and Wyman's criteria. This novel technique provided satisfactory reduction of both the femoral neck and shaft fractures with no malunion. All fractures achieved primary union, except for one case of nonunion of femoral shaft. Eight of ten patients experienced good results in functional outcome, whereas the remaining two patients reported moderate limitations in activities of daily living. At the latest follow-up, all patients had excellent range of motion in hip and knee joints. Provisional fixation after reduction of a femoral neck fracture may facilitate successful reconstruction nailing in the ipsilateral fractures of the femoral neck and shaft. This "Reverse Miss-a-Nail Technique" may minimize complications and maximize the radiologic and functional outcomes of patients who experience this injury.

Outcome of intramedullary nail for fixation of osteoporotic femoral shaft fractures in the elderly above 60

IntroductionIntramedullary nailing is an acceptable treatment option for femoral shaft fracture in young patients but not extensively studied in the elderly with osteoporotic fractures. Plate fixation for osteoporotic femoral shaft fractures have a high rate of complications and delayed healing time, and the most acceptable treatment is intramedullary nailing. This study evaluated the healing time and incidence of complications in osteoporotic femoral shaft fractures after intramedullary nailing. Patients &MethodsThis was a retrospective study that included 16 patients above 60 years old with osteoporotic femoral shaft fractures operated between January 2015 and December 2018. Patients with metastatic fractures or with atypical fractures were excluded. Thirteen patients had low-energy injuries such as a simple fall from standing height or lower and twisting injuries. The remaining 3 patients sustained high-energy-mechanism of injury. No patient received bisphosphonate except 2 patients received oral bisphosphonate for a period of 6 and 8 months, respectively. ResultsSixteen patients (12 females and 4 males) with mean age 69.5 ± 3.7 presented with femoral shaft fracture were operated with intramedullary nail, 10 patients were fixed with trochanteric entry nails with proximal neck screws, and 6 patients were fixed with piriformis entry nails. In 9 patients, closed reduction of fracture was achieved while 7 patients required open reduction, of which 5 fracture required cerclage wire addition. The mean bone healing time was 5.35±1.2 months. Intraoperative extension of femoral fractures during intramedullary nail insertion was observed in two cases that required open reduction and addition of cerclage wires around the fracture. The overall incidence of complications was 18.7%. ConclusionsIntramedullary nailing for osteoporotic femoral shaft fracture is a good acceptable option in elderly patients with reasonable healing time with no major complications.

Advantages and limitations of intramedullary nailing for the surgical treatment of ipsilateral intertrochanteric and femoral shaft fractures: a retrospective comparative study based on propensity score matching.

The aim of the present study was to introduce surgical technique using long PFNA for the treatment of ipsilateral intertrochanteric and femoral shaft fractures, and evaluate the characteristics of this fracture by comparing its surgical outcomes with those of isolated intertrochanteric and femoral shaft fractures. Between March 2013 and December 2018, 38 patients with ipsilateral intertrochanteric and femoral shaft fracture were identified at two institutions. Twenty-eight patients with ipsilateral intertrochanteric and femoral shaft fractures were enrolled in the present study. After propensity score matching, fifty-six patients with isolated intertrochanteric (group B) and femoral shaft (group C) fractures were finally enrolled in the present study for 1:2 matching to compare surgical outcomes to that of ipsilateral intertrochanteric and femoral shaft fractures (Group A). All 28 patients achieved union of intertrochanteric fractures, while two experienced non-union of femoral shaft fractures. The union time of intertrochanteric fractures in group A was significantly shorter than that in group B. The union time of femoral shaft fractures in group A was significantly longer than that in group C. The surgical treatment of ipsilateral intertrochanteric and femoral shaft fractures using long PFNA was advantageous as it allowed both fractures on the same femur to be fixed in one go and showed good surgical outcomes. However, fixation of femoral shaft fractures might be insufficient depending on the fracture level and configuration, and can be a cause of hypertrophic non-union.

Decreased Radiation Exposure Using Ultrasound-Assisted Reduction and Fixation of Femoral Shaft Fractures in Children: A Pilot Study

Elastic stable intra-medullary nail procedures have been used to treat femoral fractures in children for some time. Radiation exposure generated by intra-operative radioscopy may induce side effects in children and staff. This study introduces a method of ultrasound-assisted reduction and fixation of femoral fractures in children to decrease radiation exposure. We included 21 children and evaluated displacement of fractures using multi-section scanning. All fracture reductions were performed with ultrasonography. A hyperechoic point with a posterior acoustic shadow can be seen under the proximal and distal segments after the nail passes through the fracture site. Comparison with radioscopy suggests that this is a viable method of reduction and fixation of femoral shaft fractures in children, and can effectively decrease radiation exposure.