Intramedullary Nailing Research Articles

Neck shaft angle deviation in patients undergoing femoral limb lengthening, a retrospective study.

Previous studies have shown that subtrochanteric femoral fractures treated with intramedullary nails might lead to varus-procurvatum malalignment. Similar results have been reported when using antegrade intramedullary lengthening nails (ILNs). The purpose of our study is to examine if antegrade telescoping intramedullary lengthening nails lead to varus-procurvatum malalignment of the proximal femur and what are possible predictors of that shift. In this retrospective, single centre study, five surgeons performed 537 femoral ILN. 347 antegrade PRECICE nails were selected after applying exclusion criteria. The following exclusion criteria were applied, intentional angular deformity correction, retrograde femoral lengthening and concomitant tibial lengthening. After further exclusion criteria were applied, we retrospectively inspected 201 PRECICE nails inserted in 158 paediatric and adult patients (average age 19.9 years) that underwent IM nail limb lengthening. Follow-up was at least one year by which time all osteotomies were healed. Mean lengthening was 4.7cm per lengthening surgery with some patients needing multiple lengthening for large discrepancies. Of the 201 nails, trochanteric entry was used in 127 procedures and piriformis entry was used in 74 of them. With pre-op Osteotomy Level Coefficient (OLC) of 0.3. The preoperative neck shaft angle (NSA) was significantly reduced from 130.6 to 127.4 degrees at the end of lengthening (P < 0.05). There was no discernible correlation between the OLC and change in NSA. The trochanteric entry point was associated with a greater tendency to reduce the NSA (Mdif = -4.1, SD = 6.5) as compared to the piriformis entry point (Mdif = -3, SD 6.4) (P < 0.05). No significant change in anatomic medial proximal femoral angle (aMPFA) was noted between pre- and postoperative time points, nor between trochanteric and piriformis entry groups. Our study investigated the risk of iatrogenic varus deformity of the proximal femur following intramedullary limb lengthening procedures. We identified the osteotomy site as the most significant risk factor for developing iatrogenic varus, while the nail insertion point did not significantly predict this complication, showing comparable results for both trochanteric and piriformis entry points. Additionally, our study is the first to identify a correlation between the level of osteotomy and coxa-valga correction. We hypothesize that a higher osteotomy level might be beneficial for patients undergoing limb lengthening who also present with coxa-valga deformity. IV.

The influence of high doses of vitamin C on functional recovery and postoperative pain in patients with trochanteric fracture after intramedullary nailing during a three-month follow-up: a pilot study

&amp;lt;p&amp;gt;&amp;lt;strong&amp;gt;Aim&amp;lt;/strong&amp;gt; To determine the effects of high peri- and postoperative doses of vitamin C administration on severity of pain in postoperative period and functional outcome of the patients with trochanteric fracture treated with intramedullary nailing during a three-month follow-up.&amp;lt;br /&amp;gt;&amp;lt;strong&amp;gt;Methods&amp;lt;/strong&amp;gt; A prospective, randomized, pilot study included 56 patients who were randomly divided into vitamin C (intervention) and control groups. In the intervention group, patients received vitamin C perioperatively by an intravenous route for 2 days, and oral vitamin C for 38 days postoperatively. Baseline characteristics, postoperative metamizole consumption, Visual Analogue Scale (VAS) score, Harris Hip Score (HHS) value, and the prevalence of complications were evaluated in both groups.&amp;amp;nbsp;&amp;lt;br /&amp;gt;&amp;lt;strong&amp;gt;Results&amp;lt;/strong&amp;gt; No significant differences were noted between the groups regarding age, gender, length of hospitalization, and distribution in fracture type. Postoperative metamizole consumption was notably higher in the control group compared to the vitamin C group (p=0.006). Postoperative VAS score was higher in the control group (p&amp;amp;lt;0.05). No significant differences in HHS values were detected between the groups at 6 and 12 weeks postoperatively (p=0.655 and p=0.755, respectively). The group variable significantly contributed to VAS score, and age and gender variables significantly contributed to HHS value.&amp;lt;br /&amp;gt;&amp;lt;strong&amp;gt;Conclusion&amp;lt;/strong&amp;gt; A significant reduction of subjective pain levels and lower analgesic consumption was found in patients who received vitamin C, suggesting that it should be considered as an adjuvant agent for analgesia in patients with hip fracture.&amp;lt;/p&amp;gt;

Early Postoperative Outcomes of Surgical Fixation of Proximal Phalanx Fractures With Intramedullary Nails Versus Kirschner Wires.

Kirschner wire (K-wire) and intramedullary (IM) screw fixation are accepted techniques for treatment of unstable proximal phalanx fractures, but comparative reports are lacking. This study aimed to evaluate early clinical outcomes following treatment with K-wire or IM fixation. A retrospective review of all proximal phalanx fractures treated surgically at a single center by multiple surgeons was performed from May 1, 2019 to March 1, 2024. Inclusion criteria consisted of patients above 18 years of age with transverse or short-oblique proximal phalanx fractures, without associated soft-tissue injury or involvement of multiple digits, who were treated with IM screw or K-wire fixation. Outcomes were available for 49 patients (27 K-wire, 22 IM nail). Chart review was performed to assess range of motion (ROM) and Quick Disabilities of the Arm, Shoulder, and Hand outcomes 6 and 12 weeks postoperatively. A significant difference was found in total active motion (TAM) (207.4° vs 150.8°, P = .03) and proximal interphalangeal (PIP) joint motion (71.8° vs 54.5°, P = .04) between the IM and K-wire cohorts 12 weeks after surgery. Proximal interphalangeal motion was also significantly different (57.6° vs 34.3°, P = .03) 6 weeks after surgery with no significant difference in TAM (176.6° vs 122.1°, P = .13) at that time point. Quick Disabilities of the Arm, Shoulder, and Hand scores 12 weeks after surgery were not significantly different between the IM (M: 15.8) and K-wire (M: 28.15) groups (P = .13). Total active motion and PIP joint motion were found to be significantly higher 12 weeks postoperatively following IM fixation compared to K-wire fixation for extra-articular proximal phalanx fractures.

NUMERICAL MODEL OF A TIBIA WITH EXPOSED FRACTURE AND STABILIZATION SYSTEMS

Currently, the procedure for treating exposed comminuted mid-diaphyseal fractures in tibias consists of the use of an External Fixator (EF) linked by surgically placed screws, with the aim of repositioning and immobilizing the separate or quasi-separate parts of the bone and achieving the formation of the bony callus necessary for the regeneration of the tibia. Recent medical experiences show that the additional placement of an intramedullary rod improves the efficiency of the treatment, thus reducing the time of generation of the callus and the removal of the EF, minimizing the discomfort of the patient. In this work, the increase in stiffness provided by the intramedullary rod is quantified numerically to decrease the relative displacements between the two parts of the fractured bone. The three-dimensional modeling of an irregular body (bone) was analyzed in detail. The relative displacements between the bone and the rod, the proportions of stresses transmitted by the rod and the EF, and the connections between the bar elements and the solid elements were also investigated. A principal conclusion was an increase in the stiffness of the system by 90% on average and a reduction of relative displacements up to 20% of transverse, up to 45% longitudinal, and up to 75% torsional, for different variants of the position of the fixations, straight, and oblique fracture, and for various densities of bone, which allow validating the practical applications.

Assessment of the proficiency level of novices in distal intramedullary nail interlocking achieved through training with Digitally Enhanced Hands-on Surgical Training (DEHST).

Digitally Enhanced Hands-on Surgical Training (DEHST) platform was introduced to overcome the lack of training capabilities for the challenging task of freehand distal interlocking of intramedullary nails. It demonstrates high perceived realism for surgeons, and novices perform significantly better after DEHST training. However, characterization of how performance improves remained unexplored. The aim of this study was to evaluate the training progression of novices in freehand distal interlocking during five training rounds with DEHST and to compare their performance in a simulated operation against experienced surgeons. Ten novices (Group 1) underwent five DEHST training sessions (approximately one hour in total) and their performance data was acquired and evaluated. The surgical performance of Group 1 was compared with ten surgical experts (Group 2) by performing distal interlocking of a real tibia nail in an artificial bone model in a simulated operation. Time taken, number of X-rays, accuracy of nail hole roundness, and success rates were compared between the groups. Group 1 achieved comparable performance to Group 2 in number of X-rays 26.0 (range 15-40) versus 22.5 (range 16-34), p = 0.281, and accuracy of hole roundness 95.0% (range 91.1-98.0%) versus 93.3% (range 90.7-95.9%), p = 0.087. However, Group 1 needed significantly longer time compared with Group 2, p = 0.001, and furthermore, one participant in Group 1 (10%) failed to hit the nail hole with the drill bit, while 100% of the participants in Group 2 were successful. DEHST appears to be a useful tool to gradually improve the proficiency level of novices and to train relevant practical surgical skills needed for distal interlocking of intramedullary nails. However, further investigations are needed to demonstrate the performance under the conditions of a real operation.

Exploring Outcomes of Tibial Rigid Intramedullary Nailing in Adolescent Patients.

To explore outcomes after tibial rigid intramedullary nailing (RIMN) in skeletally immature patients, with a focus on post-operative complications and iatrogenic changes in tibial slope due to anterior physeal arrest. Design: Retrospective case series. A large, tertiary care health system in the rural Mid-Atlantic United States, including two Level 1 trauma centers and one Level 2 trauma center. Included were skeletally immature patients within 2 years of skeletal maturity undergoing tibial RIMN for OTA/AO 42 A to C fractures between March 2009 and January 2024 with post-operative follow-up more than 1-year. The primary outcome was change in tibial slope after RIMN. Secondary outcomes included post-operative weight-bearing status and complications. Thirty-seven skeletally immature patients were included (mean age 15.2 ± 1.3 years, 76% male). For 22 patients with minimum 6-month post-operative radiographs (mean 18.4 ± 12.7 months), there was no significant change from pre- to post-operative tibial slope (80.0 ± 1.9° vs 80.1 ± 1.6°, p=0.86). Time to achievement of full weightbearing across the series averaged 45.4 ± 35.6 days. Five (14%) of patients necessitated hardware removal, and 89% of patients reported they had returned to "normal" activity at latest follow-up (mean 56.2 ± 42.5 months). This study demonstrated that RIMN for tibial shaft fractures in skeletally immature pediatric patients within 2 years of maturity was not associated with iatrogenic physeal injury and resultant changes in tibial slope. Additional favorable clinical outcomes, the potential for early weight-bearing, and few associated post-operative complications, indicate that RIMN is a safe option for skeletally immature patients with tibial shaft fractures. Caution should be exercised when extrapolating these results to younger pediatric patients with >2 years of skeletal growth remaining. IV.

Mechanical Failure of the Stryker T2 Alpha Retrograde Femoral Nail.

To evaluate mechanical failure rates of retrograde femoral nails in the treatment of distal femur fractures. Design: Retrospective chart review. Urban Academic Level 1 Trauma Center. Included were adult patients who sustained a distal femur fracture (AO/OTA 33) who were treated with a retrograde intramedullary nail from August 2021 through September 2022. The primary outcome was the rate of mechanical failure of the intramedullary nail defined as deformation and/or breakage of the intramedullary nail. The rate of mechanical failure was compared amongst retrograde femoral nails used at the same institution during the same time period. One hundred and twenty distal femur fractures were identified (77 native distal femur, 43 periprosthetic) that were treated with a retrograde intramedullary nail. Average patient age was 67 years (SD 15.1, range 18-96 years). Eighty-three (69.2%) of patients were female. Four mechanical nail failures (deformation and/or breakage of the intramedullary nail) were observed within six months of surgery, two in patients with native distal femur fractures, and two in patients with periprosthetic distal femur fractures. All failures occurred among forty-nine fractures treated with a newly released retrograde femoral nail, the T2 Alpha Retrograde Femoral Nail (Stryker, Mahwah, NJ). This represents an 8.2% mechanical failure rate of distal femur fractures treated with this new nail compared to no failures observed with any other nail (p=0.03). Mechanical nail failures, within six months of surgery for distal femur fracture, of a new retrograde femoral nail were observed to be higher than seen with other nails. Further evaluation is needed to determine if this experience represents factors related to patient, injury, or surgical characteristics, an anomaly, or a safety signal. Therapeutic Level III. See instructions for authors for a complete description of levels of evidence.

Clinical and Functional Outcomes of Peri-Implant Fractures Associated with Short Proximal Femur Nails: Prevention Strategies and Key Insights.

Background: Hip fractures are prevalent among the elderly and impose a significant burden on healthcare systems due to the associated high morbidity and costs. The increasing use of intramedullary nails for hip fracture fixation has inadvertently introduced risks; these implants can alter bone elasticity and create stress concentrations, leading to peri-implant fractures. The aim of this study is to investigate the outcomes of peri-implant hip fractures, evaluate the potential causes of such fractures, determine the type of treatment provided, assess the outcomes of said treatments, and establish possible improvement strategies. Methods: We conducted a retrospective observational study on 33 patients with peri-implant hip fractures (PIFs) who underwent surgical management at Río Hortega University Hospital from 2010 to 2022. The collected data included demographics, initial fracture characteristics, the peri-implant fracture classification, implant details, surgical outcomes, functional scores, and complications. Functional capacity was evaluated using the Parker Mobility Score (PMS). Results: The cohort (91% female, mean age 87.6 years) included 34 peri-implant fractures. The mean time from the initial fracture to the PIF was 47.2 months (nine patients developed PIFs within 2 months). Most fractures (76%) were managed with implant removal and the insertion of a long intramedullary nail, with cement augmentation in 31% of cases. The mean surgical time was 102 min, and the average hospital stay was 9.6 days. Postoperative complications occurred in 27%, with a perioperative mortality rate of 9%. Functional capacity showed a significant decline, with an average PMS loss of 4.16 points. Mortality at one year post-PIF was 36%, rising to 83% at five years. Radiographic consolidation was observed in 72% of cases at an average of 6.04 months, though 24% of patients died before consolidation. Statistically significant correlations were found for PMS pre-index fracture (PMS1: r = 0.354, p < 0.05), pre-PIF (PMS2: r = 0.647, p < 0.001), and post-PIF (PMS3: r = 0.604, p < 0.001). Conclusions: Peri-implant hip fractures present complex challenges due to their surgical difficulty and impact on patient mobility and survival. Successful management requires individualized treatment based on fracture type, implant positioning, and patient factors. These findings underscore the need for preventive measures, particularly in implant choice and techniques like overlapping and interlocking constructs, to minimize the secondary fracture risk.

Anterior Knee Pain and Knee Functional Scores Following Common Approaches to Tibial Shaft Fractures: A Systematic Review.

Tibial shaft fractures are common, causing substantial morbidity. Intramedullary nailing offers advantages but often leads to anterior knee pain and functional issues. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review on outcomes for different surgical approaches-suprapatellar (SP), infrapatellar (IP), medial parapatellar (MPP), and lateral parapatellar (LPP). Searches across Ovid, Embase, and PubMed identified studies from 2000 to 2023, including retrospective and prospective studies, randomized controlled trials, and case series on anterior knee pain and functional outcomes postsurgery. Bias was assessed using Cochrane's RoB2. Of 27 studies, 8 were noncomparative (3 SP, 3 IP, 1 MPP, 1 LPP), showing varied anterior knee pain and function outcomes. Comparative studies (12 SP vs. IP, 5 MPP vs. IP) indicated better patient-reported outcomes for SP over IP in anterior knee pain and knee function. Comparative data for MPP and LPP remain limited. Overall RoB was low. SP has better patient-reported outcomes and lower anterior knee pain than IP. MPP and LPP approaches are promising but lack robust comparative data. Further large, prospective trials are needed to clarify optimal approaches for tibial shaft fractures. Level III. See Instructions for Authors for a complete description of levels of evidence.

Closed Management of a Bent Tibial Nail: Can Revision Be Avoided?: A Case Report.

A 49-year-old gentleman sustained a closed, right tibia peri-implant fracture with a bent intramedullary nail. This resulted in a 17° valgus and 5° recurvatum deformity with fracture at the distal third of the tibial shaft. The patient underwent closed manipulation with an F-Tool and was reviewed by our unit over the following year. This is the first case report of closed manipulation of a tibial fracture over a bent implant. This approach was successful in correcting deformity to within acceptable limits, achieved radiological union, and was associated with excellent patient-reported outcomes at all points of follow-up.

An alternative choice for overweight pediatric patient with femoral shaft fracture when rigid nail is contraindicated due to narrow intramedullary canal: Elastic stable intramedullary nail plus temporary external fixator.

Length unstable femoral shaft fractures in school-aged children usually demand surgical treatment, but the optimal choice remains controversial, especially in overweight adolescents. This study aimed to compare the clinical results of locking compression plates (LCP) and elastic stable intramedullary nails (ESIN) combined with temporary external fixator (TEF) in school-aged children weighing over 50kg. Between January 2010 and January 2018, children over 50kg with length unstable femoral shaft fracture treated with ESIN & EF in the authors' institute were included in this study. Adolescent patients with matched age, sex, body weight and fracture type receiving LCP were retrieved from hospital database. The Flynn Score System was used to evaluate the clinical outcomes of treatments at the last follow-up. A total of 30 young children aged 10-14 years were included. Fifteen patients (9 male and 6 female) received ESIN & EF treatment, while the other fifteen (9 male and 6 female) received LCP treatment. All patients were followed up for more than 12 months post-surgery (14-26 months). In all, less operation time, less estimated blood loss and shortened hospital stay (P<0.001), faster union time (P=0.031) were observed in ESIN & EF group, compared with the Plating group. All surgeries in the ESIN & EF group were performed without exposing the fracture site. In contrast, 60% (9/15) of the surgeries in the Plating group were performed with the fracture site exposed. Every patient scored satisfactory or excellent on the Flynn Score System without major complications demanding revision surgeries. ESIN plus EF produces satisfactory clinical outcome for overweight pediatric patients with femoral shaft fracture when rigid nail is contraindicated due to narrow medullary canal.

Stress Analysis in Conversion Total Hip Arthroplasty: A Finite Element Analysis on Stem Length and Distal Screw Hole.

Background/Objectives: Proximal femoral fractures are particularly common in older adults, and cases requiring conversion to total hip arthroplasty may arise because of treatment failure or osteoarthritis. Fractures around the distal screw removal holes can be problematic. This study aimed to analyze the relationship between stem length and femoral stress distribution to determine the optimal stem length. Methods: A finite element analysis simulation was conducted using pre-existing femoral computed tomography data, an intramedullary nail, and three types of stems of varying lengths. Loads simulating normal walking and stair climbing were applied, and the average and maximum equivalent stresses were measured on both the medial and lateral sides of the distal screw removal hole for each stem length. Statistical analysis was then performed to evaluate the stress distributions. Results: The average stress around the distal screw removal hole tended to decrease as stem length increased. The maximum stress was significantly lower with the 160-mm stem, which provides a 40-mm bridging length, compared to the 120-mm and 130-mm stems, where the stem tip aligned with or only slightly extended past the distal screw removal hole (bridging lengths of 0 mm and 10 mm, respectively). Conclusions: In conversion hip total arthroplasty following proximal femoral fractures, using a sufficiently long stem can help avoid stress concentration around the distal screw removal hole, thereby potentially reducing the risk of periprosthetic fractures.

Analysis of the terms of development of infectious complications in patients after osteosynthesis of long bones

Determination of the influence of the timing of infectious complications in patients after osteosynthesis of long bones and its influence on the course of the infectious process. An analysis of the treatment of 207 patients with infectious complications after osteosynthesis of long bones, who were treated at the "Institute of Traumatology and Orthopedics of the National Academy of Medical Sciences of Ukraine" from 2013 to 2017 was made. The first group included 148 patients who developed infectious complications after osteosynthesis of long bones with a plate. The second group included 59 patients who developed infectious complications after osteosynthesis of long bones with a blocking intramedullary rod. In 51.5% of patients of the first group after closed fractures, infectious complications were detected in the first 6 weeks after surgery. In 43.7% of patients of this group, manifestations of the inflammatory process occurred in the period from 6 weeks to 1 year. In 4.9% of patients of the first group, the infectious process (in the form of a fistula) did not occur acutely, but after one year after osteosynthesis. In 62.2% of patients after osteosynthesis as a result of an open fracture, the first manifestations of the infectious process appeared in the first 6 weeks after the operation. In 35.6% of patients of this cohort, the infectious process occurred within 6 weeks to 1 year after the surgical intervention. In 43.2% of patients of the second group, the first manifestations of infection began immediately after the operation in the form of non-healing of the postoperative wound, and in another 24.3% – in the first 6 weeks after the intervention. In 32.4% of patients in this cohort, an infectious process occurred more than a year after the intervention against the background of a consolidated fracture and a stable fixator. After BIOS with rod as a result of open fractures, in 72.7% of patients, the infectious process began immediately after the operation in the form of non-healing of the postoperative wound, and in another 27.3% – in the first 6 weeks after the intervention. The terms of the infection after osteosynthesis and its type reliably affect the development of complications in the injured person and have an indirect effect on their development. The structure of infectious complications is different depending on the time of occurrence and the type of osteosynthesis used to treat patients. In all observation groups, the infectious process localized in the tibia, which has both anatomical reasons and reasons related to the blood supply of this segment, was detected the most often.

Septic Nonunion of the Tibial Shaft with Bone Defect in a Gustilo-anderson Type II Open Fracture

Introduction. Open fractures of the tibial shaft are mostly the result of high-energy trauma, the incidence is 17 to 21 per 100,000 inhabitants, represent 2% of all fractures and 36.7% of all long bone fractures in adults. More than 15% of tibial shaft fractures are classified as open, representing the most common open long bone injuries. The reported incidence of nonunion or delayed union of tibial shaft fractures after intramedullary nailing (IMN) ranges from 16% to 36%. Infection can complicate any stage of the fracture healing process and may contribute to nonunion in up to 38% of cases. Case: A 64yo female with open fracture of the tibial shaft G-A II, initially treated with external fixators, then 3 internal fixations with IMN were performed at different surgical times due to complication of septic nonunion, managed with local and systemic antibiotics and tissue coverage. Discussion: Some orthopedic surgeons prioritize bone union as the main treatment goal in septic nonunion and advocate retaining the implant with surgical cleaning and debridement of devitalized tissue, followed by suppressive intravenous antibiotic therapy. Conversely, others consider eradicating the infectious process as the most critical stage of treatment. Conclusion: Pseudoarthrosis is one of the most devastating problems in orthopedic surgery. We consider it a priority to identify the pathogen associated with the nonunion for specific local and systemic antibiotic therapy associated with aggressive debridement surgery and stable fixation.

Is Submuscular Plating as Effective and Safe as Elastic Stable Intramedullary Nailing for Pediatric Diaphysial Fractures of the Femur?

Is Submuscular Plating as Effective and Safe as Elastic Stable Intramedullary Nailing for Pediatric Diaphysial Fractures of the Femur?

Pediatric Tibial Shaft Fractures: A Comprehensive Review

Tibial shaft fractures are among the most common pediatric long bone fractures. These fractures have significant implications for growth, function and alignment, often requiring precise management to prevent complications such as limb length discrepancies and angular deformities. This review focuses on the classification, etiology and management of pediatric tibial shaft fractures, emphasizing recent advancements and remaining challenges. A comprehensive literature review was conducted in November 2024 using PubMed, Medline and Scopus. Articles were selected based on relevance to etiology, classification and management strategies. Both recent and foundational studies were included to provide a comprehensive perspective. The review explores the major types of tibial shaft fractures in children, including Toddler’s fractures (and spiral fractures), transverse fractures, greenstick fractures, stress fractures, segmental fractures and comminuted fractures, focusing on their etiology, age-specific prevalence, clinical presentation, imaging findings, management strategies and potential complications. Younger children typically experience fractures due to low-energy mechanisms, such as twisting injuries, resulting in spiral or greenstick fractures. Older children and adolescents are more prone to high-energy trauma, causing transverse, comminuted or segmental fractures, often associated with fibular involvement. Most fractures are treated non-operatively using casting techniques tailored to fracture stability, angulation and age. Surgical interventions, including flexible intramedullary nailing, external fixation and plating, are reserved for complex or unstable fractures, open injuries or cases involving neurovascular compromise. Advances in classification systems, imaging modalities and surgical techniques have improved outcomes, yet opportunities exist to develop growth-preserving methods and improve long-term functional recovery. Future research should prioritize optimizing individualized management strategies and exploring innovative technologies to enhance diagnostic accuracy and treatment efficacy.

Nail-plate combination constructs versus single traditional constructs for distal femur fractures: a systematic review and meta-analysis of comparative studies.

Distal femur fractures (DFF) are frequently treated surgically with single traditional constructs (STC), such as with a lateral plate or intramedullary nail, although nail-plate combination constructs (NPCC) are gaining attention. The purpose of this study is to compare outcomes between NPCC and STC for surgical fixation of DFF to guide surgeon decision-making. Data Sources: This study is a systematic review and meta-analysis using PubMed, CINAHL, MEDLINE, Web of Science, Science Direct, and SPORTDiscus from database inception until January 10th, 2024. Inclusion criteria were comparative studies that examined clinical outcomes and complications for NPCC versus STC for DFF in adult patients. Data included operative time, estimated blood loss (EBL), length of stay (LOS), as well as likelihood of total complications, total unplanned reoperations, and malunion. Statistical analysis included a random-effects model using unstandardized mean difference or odds ratio (OR). Five retrospective comparative studies (n = 1,368 patients; mean age: 52.3 ± 8.1 years; 134 patients in the NPCC group) were included. There was no statistically significant difference in operative time (p = 0.696), EBL (p = 0.408), or LOS (p = 0.963) between patients in the NPCC group as compared to patients in the STC group after DFF. Patients in the NPCC group had a statistically significant lower number of total complications (p = 0.009; OR: 0.31; 10.6% versus 16.0%) and total unplanned reoperations (p = 0.027; OR: 0.42; 8.2% versus 14.8%) as compared to patients in the STC group after DFF. However, there was no statistically significant difference in the number of malunion cases between groups (p = 0.130), although the NPCC group had far fewer cases than the STC group (2.9% versus 10.5%). Patients treated with NPCC had significantly fewer cases of total complications and total unplanned reoperations without significant differences in operative time, EBL, or LOS as compared to patients treated with STC for DFF, although these associations are limited by sample size. Level IV.

Comparison of Short-Term Clinical Outcomes of the DePuy Synthes Femoral Reconstruction Nail with the Synthes Expert Retrograde/Antegrade Femoral Nail for Intramedullary Nailing in Femoral Shaft Fractures

Objectives The objective of this study is to compare the complications, rates of reoperation, and related secondary measures between two devices used to manage femoral shaft fractures: the DePuy Synthes Femoral Recon Nail (FRN) and its predecessor, the DePuy Synthes Expert Retrograde/Antegrade Femoral Nail (R/AFN). The primary null hypothesis was that the two devices had no significant difference in the clinical outcomes. Our secondary hypothesis was that there is no significant difference in the duration of surgery between the two devices. Methods This study reviewed charts of all patients aged 18-89 who underwent antegrade intramedullary nailing for a femoral shaft fracture, subtrochanteric femur fracture, or a combined femoral neck/shaft fracture with either a FRN or a R/AFN from January 1st, 2010, to April 1st, 2022, at a single level 1 trauma center. A total of 88 subjects were identified for study inclusion: 30 patients who underwent fixation with the R/AFN system and 58 patients who received treatment with the FRN system. These subjects’ charts and radiographs were then analyzed for patient characteristics, fracture characteristics, radiographic outcomes, and clinical outcomes. Statistical significance between variables was ascertained using chi-squared analysis and t-tests. Significant results were confirmed via power analysis with a two-sample t-test and normalization for demographic differences using linear regression. Results Average body mass indexes (BMIs) were 24.6±4.4 kg/m2 and 27.9±4.6 kg/m2 for the R/AFN and FRN groups, respectively (P=.002). The duration of surgery was 2.4±1.0 hours for the R/AFN cohort and 3.1±1.1 hours for the FRN cohort (P=.01). No statistically significant differences were found in the clinical outcomes between the two devices. Conclusion The FRN has short-term clinical outcomes comparable to the R/AFN in terms of safety and efficacy.

Advancing care for congenital pseudoarthrosis: A case series highlighting the combined use of an intramedullary device with either Ilizarov’s fixators or plating for the treatment of congenital pseudoarthrosis

Congenital pseudarthrosis of the tibia (CPT) is a bone defect in which non-union occurs in a dysplastic segment of the tibial diaphysis following a fracture at the same site. Once a fracture occurs through a susceptible bone and pseudoarthrosis is formed, spontaneous healing is unexpected. Therefore, surgical intervention is essential for healing. This study aimed to compare the outcomes of using intramedullary nailing with either Ilizarove’s fixator or plating as a treatment method for CPT to other treatment methods described in the literature. This case series study included nine patients who presented to the Pediatric Orthopedic clinic with CPT from 2018 to 2021. All patients were previously diagnosed with Neurofibromatosis-1 by pediatric genetics and presented with unilateral CPT. The minimum follow-up duration was 12 months. Nine patients were diagnosed with neurofibromatosis. Of the nine patients, fixation was supplemented with an Ilizarov external fixator in 5 patients, and the plate was used in 4 patients. Most patients (88.9%) achieved union, except for one patient with an infection requiring multiple surgical debridement. The type of fixation was not significantly associated with the union rate. In conclusion, patients who underwent intramedullary nailing in conjugation with Ilizarov’s fixator or plating for the treatment of CPT and cross-union have achieved excellent union rates with no refracture in early outcomes.

Arthrodesis in the treatment of ankle osteoarthritis due to neglected malleolar fractures in the elderly.

Neglected malleolus fracture cases, among other conditions in which arthrodesis is inevitable, usually present with pseudoarthrosis of the malleolus and impaired ligament balancing. The study aimed to summarize the clinical data results of neglected malleolus fractures accompanied by ankle instability. The retrospective study was conducted at Adana City Training and Research Hospital. The files of the patients diagnosed with nonunion malleolus fractures admitted between January 1, 2018, and July 30, 2023, were analyzed. In addition to the demographics, the type of malleolus fracture, the technique used in arthrodesis surgery, use of graft, union status, presence of early and late complications, visual analog scale (VAS), and Maryland Foot Score (MFS) scores at preoperative, 3-, 6-, and 12-month postoperative visits were recorded. There was a total of 11 files available for analysis. The mean age of the cases was 70.55 ± 5.03, ranging between 65 and 82. The records showed that the patients ignored the need for surgical treatment for an average of 10.64 ± 3.5 months. In terms of the technique, 4 were treated using the Ilizarov only, 3 with the intramedullary nails, 3 with plates and screws, and the remaining Ilizarov and plate. The average duration of the union was 6.27 ± 2.99 months. The mean VAS scores for preoperative, postoperative 3rd, postoperative 6th, and postoperative 12th months were 7.55 ± 0.78, 5.55 ± 2.31, 3.45 ± 2.27, and 2.45 ± 1.44, respectively. The mean Maryland Foot Scores (MFS) for preoperative, postoperative 3rd, postoperative 6th, and postoperative 12th months were 21.82 ± 6.85, 51.27 ± 15.39, 61.18 ± 20.21, and 70.82 ± 5.27, respectively. This study has shown that no matter how difficult the case, if the appropriate implant and basic arthrodesis principles are followed, the union can be achieved, albeit late, in cases with osteoarthritis due to neglected ankle malleolus fracture. Especially in the presence of infection, it should be kept in mind that union may be delayed compared to the regular arthrodesis recovery duration, requiring the team performing the surgery to be familiar with the Ilizarov technique.