Intramedullary Fixation Of Fractures Research Articles

Improving agreement in assessing subtrochanteric fracture healing among orthopedic surgeons using the Radiographic Union Score for Hip (RUSH)

BackgroundPrompt identification of fracture healing is crucial for medical decision-making and clinical research. This study aims to assess the effectiveness of the Radiographic Union Score for Hip (RUSH) in subtrochanteric fractures and determine the optimal scoring threshold for fracture healing.MethodsWe obtained 94 sets of X-ray films from the postoperative follow-up of 35 patients who underwent intramedullary nail fixation for subtrochanteric fractures. Six orthopedic trauma surgeons evaluated the imaging data and determined fracture healing based on subjective judgment. They then scored the X-ray images using the RUSH form. After four weeks, the same observers re-evaluated 47 randomly selected sets of radiographs. Subsequently, the observers and study designer conducted a consensus meeting where they agreed on whether the fractures had healed. We used Fleiss kappa to evaluate agreement among observers based on subjective impressions, and the intraclass correlation coefficient assessed RUSH score consistency. Regression analysis examined the relationship between scores and fracture healing consensus using a receiver operator characteristic (ROC) curve.ResultsBased on overall impressions, the agreement level among orthopedic trauma surgeons for determining the healing status of subtrochanteric fractures was moderate (Kappa = 0.564, 95% CI: 0.511–0.616). However, utilizing the RUSH scoring system can improve the consistency to a substantial level of agreement (ICC = 0.748, 95% CI: 0.663–0.817). Regarding intraobserver reliability, there were significant differences among orthopedic trauma surgeons in judging fracture healing based on overall impressions. However, using the RUSH scoring form, the attending group achieved better intraobserver consistency than the resident group. Regression analysis and ROC curve analysis revealed a strong correlation between the RUSH total score, cortical bone score, cancellous bone score, and consensus on fracture healing. The AUC values are 0.769 (95% CI: 0.670–0.868), 0.779 (95% CI: 0.681–0.876), and 0.771 (95% CI: 0.674–0.867), respectively.ConclusionsOur study highlights the effectiveness of the RUSH scoring system in enhancing interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing in orthopedic trauma surgeons. We propose setting 21 points as the threshold for the simplified RUSH scoring system to determine fracture healing. This system includes only eight items related to cortical bone, with a total score of 24 points.

Impact of operative position on rotational alignment after intramedullary nailing of trochanteric fractures: a comparative analysis of lateral decubitus versus supine position.

Fixation of trochanteric fractures with an intramedullary nail in a non-physiological position can cause poor functional outcomes. The aim of this study is to evaluate the effect of intraoperative patient position on rotational alignment in intramedullary nail fixation of trochanteric fractures. The femoral rotational alignment of 84 trochanteric fracture patients who underwent intramedullary nailing was measured by computed tomography (CT) images. Patients were divided into two groups: the supine position on the fracture table (FT) (Group 1, n = 42) and the lateral decubitus (LD) position (Group 2, n = 42). Femoral malrotation angles were measured and divided into three subgroups: insignificant, significant,andexcessive.The number of intraoperative fluoroscopy images, preparation time, surgery time, and anesthesia time in both groups were compared. The malrotation degrees of patients in Group 1 ranged from 17° external rotation (ER) to 57° internal rotation (IR), with a mean of 10° IR. Of the patients in Group 1, 27 were insignificant, 5 were significant, and 10 were in the excessive subgroup. The malrotation degrees of patients in Group 2 ranged from 33° ER to 47° IR, with a mean of 11° IR. Of the patients in Group 2, 21 were insignificant, 12were significant, and 9 were in the excessive subgroup. There was no statistically significant relationship between patient position and malrotation angle. The number of intraoperative fluoroscopy images, preparation time, and anesthesia time were statistically lower in Group 2. There was no statistically significant difference between Group 1 and Group 2 in terms of surgery time. Intramedullary nailing in the LD position is a reliable and practical surgical method in the treatment of femoral trochanteric fractures since there is no need for the use of a FT, the surgeon is exposed to less radiation, there is no risk of complications related to the traction of the FT, and there is a shorter operation time.

A Biomechanical Analysis of Oblique Metacarpal Metadiaphyseal Fracture Fixation in a Cadaver Model

Although metacarpal fractures are typically managed nonoperatively, when surgical management is indicated, metacarpal fractures are commonly treated with crossed Kirschner wires (K-wires), which may limit early range of motion. Intramedullary implants are increasing in use with the potential advantage of early range of motion; however, stability in oblique metacarpal neck fractures remains a theoretical concern. The purpose of this study was to determine the biomechanical stability of noncompressive intramedullary fixation for oblique metacarpal neck fractures compared with crossed K-wire fixation. The index, long, and small metacarpals were harvested from three matched pairs of fresh-frozen cadavers. Oblique fractures at the metadiaphyseal region were created in each metacarpal. Each metacarpal was randomized to noncompressive, threaded intramedullary nail fixation or fixation with two crossed K-wires. Specimens were mounted in a Materials Testing System load frame and axially loaded until failure. Load to failure (LTF), stiffness, and load to 2 mm displacement were calculated from load-displacement curves. Differences in peak LTF, stiffness, and load to 2 mm displacement between noncompressive intramedullary fixation and crossed K-wire fixation were evaluated. The noncompressive intramedullary fixation cohort had a significantly higher LTF (1,190.9 ± 534.7 N vs 297.0 ± 156.0 N) and stiffness (551.3 ± 164.6 N/mm vs 283.0 ± 194.5 N/mm) when compared with the crossed K-wire fixation cohort. Load at 2 mm displacement was greater in the noncompressive intramedullary fixation cohort compared with crossed K-wire fixation (820.5 ± 203.9 vs 514.1 ± 259.6). For oblique metadiaphyseal metacarpal fractures, noncompressive intramedullary fixation provides a biomechanically superior construct under axial loading in terms of LTF, stiffness, and load to 2 mm of displacement compared with crossed K-wire fixation. Noncompressive intramedullary nails may be an alternative to K-wire fixation for the treatment of oblique metadiaphyseal metacarpal fractures.

A clinical study on robot navigationassisted intramedullary nail treatment for humeral shaft fractures

BackgroundThe purpose of this study was to evaluate the advantages of robot navigation system-assisted intramedullary nail treatment for humeral shaft fractures and compare it’s efficacy with that of traditional surgical intramedullary nail treatment.Materials and methodsThis was a retrospective analysis of patients with humeral shaft fractures who received intramedullary nail treatment at our centre from March 2020 to September 2022. The analysis was divided into a robot group and a traditional surgical group on the basis of whether the surgery involved a robot navigation system. We compared the baseline data (age, sex, cause of injury, fracture AO classification, and time of injury-induced surgery), intraoperative conditions (surgery time, length of main nail insertion incision, postoperative fluoroscopy frequency, intraoperative bleeding), fracture healing time, and shoulder joint function at 1 year postsurgery (ASES score and Constant–Murley score) between the two groups of patients.ResultsThere was no statistically significant difference in the baseline data or average fracture healing time between the two groups of patients. However, the robotic group had significantly shorter surgical times, longer main nail incisions, fewer intraoperative fluoroscopies, and less intraoperative blood loss than did the traditional surgery group (P < 0.001).ConclusionRobot navigation system-assisted intramedullary nail fixation for humeral shaft fractures is a reasonable and effective surgical plan. It can help surgeons determine the insertion point and proximal opening direction faster and more easily, shorten the surgical time, reduce bleeding, avoid more intraoperative fluoroscopy, and enable patients to achieve better shoulder functional outcomes.

Challenges of perioperative pain control in opioid use disorder patients following intramedullary nail fixation.

Outcomes of patients with opioid use disorder undergoing elective procedures have been well studied, but research is lacking in the orthopaedic trauma population. The aim was to compare perioperative pain and morphine equivalents required by patients with versus without opioid use disorder following intramedullary nail fixation of femoral or tibial fractures. We conducted a retrospective review of all patients with isolated femoral or tibial diaphyseal fractures treated with intramedullary nail fixation. Outcomes were compared between patients with diagnosed opioid use disorder and controls without, including daily morphine equivalents and patient-reported pain scores. Patients with opioid use disorder (n = 42) required greater morphine equivalents and reported higher pain than controls (n = 42) at all time points but did not differ in change of morphine equivalents over the perioperative period. This highlights the challenge of perioperative pain control in this population and need for improved specific pain management protocols.

Surgical treatment of forefoot and midfoot fractures : Minimally invasive fixation of metatarsal fractures

Minimally invasive stabilization of metatarsal fractures to enable adequate fracture healing in acorrect position to restore anatomy and biomechanics of the foot. A.Dislocated diaphyseal and subcapital fractures of the second to fifth metatarsal (> 3 mm, > 10° dislocation). B.Fifth metatarsal fracture at the metadiaphyseal junction (Lawrence and Botte typeIII). High grade soft tissue damage or infection at the implant insertion site. A.Fluoroscopically assisted closed reduction and antegrade intramedullary fixation of diaphyseal and subcapital fractures of the second to fifth metatarsal. B.Fluoroscopically assisted wire-guided intramedullary screw fixation of fifth metatarsal fractures at the metadiaphyseal junction. A.Mobilization with partial weight bearing (20 kg) for 6weeks wearing astiff sole; implant removal under local anesthesia after 6-8weeks, followed by afree range of movement and weight-bearing as tolerated (WBAT). B.Early mobilization with weight-bearing as tolerated (WBAT); removal of the orthosis after 6weeks, implant removal optional. A.Antegrade nailing of subcapital and shaft fractures of metatarsalsII-V achieves good clinical results with low complication rates both when using prepared Kirschner wires or elastically stable intramedullary nails (ESIN). B.According to current literature, intramedullary screw osteosynthesis of proximal metatarsalV fractures of zoneII andIII according to Lawrence and Botte leads to faster bony healing with alower nonunion rate compared with conservative treatment. It is recommended especially, but not only, for active athletes.

The Intermalleolar Method for Intraoperative Rotational Assessment of the Tibia-A Prospective Clinical Validation Study.

To determine the accuracy of the intermalleolar method, an intraoperative fluoroscopic method for assessing tibial rotation in patients undergoing intramedullary nail fixation for tibial shaft fractures, by comparing it with the gold standard computed tomography (CT). Prospective cohort study. Academic Level 1 trauma center. Consecutive patients, aged 18 years and older, with unilateral tibial shaft fractures who underwent intramedullary fixation from September 2021 to January 2023. Intraoperatively, tibial rotation measurements were obtained using the intermalleolar method on both the uninjured and injured limbs. Postoperatively, patients underwent bilateral low-dose lower extremity rotational CT scans. CT measurements were made by 4 blinded observers. Mean absolute rotational differences and standard errors were calculated to compare the injured and uninjured limbs. Subgroup analysis was performed assessing accuracy relating to injured versus uninjured limbs, body mass index, OTA/AO fracture pattern, tibial and fibular fracture location, and distal articular fracture extension requiring fixation. Of the 20 tibia fractures, the mean patient age was 43.4 years. The intermalleolar method had a mean absolute rotational difference of 5.1 degrees (standard error 0.6, range 0-13.7) compared with CT. Sixty percent (24/40) of the measurements were within 5 degrees, 90% (36/40) of the measurements were within 10 degrees, and 100% (40/40) were within 15 degrees of the CT. No patients were revised for malrotation postoperatively. The intermalleolar method is accurate and consistently provides intraoperative tibial rotation measurements within 10 degrees of the mean CT measurement for adult patients undergoing intramedullary nail fixation for unilateral tibial shaft fractures. This method may be employed in the operating room to accurately quantify tibial rotation and assist with intraoperative rotational corrections. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary headless screw fixation for fractures of the proximal phalanges of the hand: a three-year follow-up

ObjectiveThe objective of this study was to evaluate the long-term outcomes of trans-articular intramedullary fixation using cannulated headless screws for proximal phalanx fractures in the hand.BackgroundVarious surgical techniques have been described for the fixation of proximal phalanx fractures, with Kirschner wires, plates, and screws being commonly used. The objective of this study was to evaluate the long-term outcomes of trans-articular intramedullary fixation using cannulated headless screws for proximal phalanx fractures in the hand. Methods Eight patients, with nine proximal phalanx fractures, treated with intramedullary screw fixation, were included for a follow-up visit three years post-surgery. Subjective and objective outcome measures were assessed using the Michigan Hand Questionnaire (MHQ), active range of motion (aROM), grip strength, conventional X-rays, and digital tomosynthesis images.MethodsEight patients, with nine proximal phalanx fractures, treated with intramedullary screw fixation, were included for a follow-up visit three years post-surgery. Subjective and objective outcome measures were assessed using the Michigan Hand Questionnaire (MHQ), active range of motion (aROM), grip strength, conventional X-rays, and digital tomosynthesis images.ResultsWe observed a mean MHQ score of 83%, a total aROM of 216.4°, and a Jamar grip strength of 29.9 kg in the injured hand. Digital tomosynthesis revealed complete fracture consolidation in all cases. Joint arthrosis was detected in only one case, attributed to a misplaced screw.ConclusionsOur findings indicate favorable long-term clinical outcomes, including range of motion, grip strength, patient satisfaction, and prevention of joint damage, with the use of intramedullary headless screw fixation.Level of evidence: Level IV, Therapeutic

Impaired synaptic plasticity and decreased glutamatergic neuron excitability induced by SIRT1/BDNF downregulation in the hippocampal CA1 region are involved in postoperative cognitive dysfunction

BackgroundPostoperative cognitive dysfunction (POCD) is a common complication after anesthesia/surgery, especially among elderly patients, and poses a significant threat to their postoperative quality of life and overall well-being. While it is widely accepted that elderly patients may experience POCD following anesthesia/surgery, the exact mechanism behind this phenomenon remains unclear. Several studies have indicated that the interaction between silent mating type information regulation 2 homologue 1 (SIRT1) and brain-derived neurotrophic factor (BDNF) is crucial in controlling cognitive function and is strongly linked to neurodegenerative disorders. Hence, this research aims to explore how SIRT1/BDNF impacts cognitive decline caused by anesthesia/surgery in aged mice.MethodsOpen field test (OFT) was used to determine whether anesthesia/surgery affected the motor ability of mice, while the postoperative cognitive function of 18 months old mice was evaluated with Novel object recognition test (NORT), Object location test (OLT) and Fear condition test (FC). The expressions of SIRT1 and other molecules were analyzed by western blot and immunofluorescence staining. The hippocampal synaptic plasticity was detected by Golgi staining and Long-term potentiation (LTP). The effects of SIRT1 and BDNF overexpression as well as chemogenetic activation of glutamatergic neurons in hippocampal CA1 region of 18 months old vesicular glutamate transporter 1 (VGLUT1) mice on POCD were further investigated.ResultsThe research results revealed that older mice exhibited cognitive impairment following intramedullary fixation of tibial fracture. Additionally, a notable decrease in the expression of SIRT1/BDNF and neuronal excitability in hippocampal CA1 glutamatergic neurons was observed. By increasing levels of SIRT1/BDNF or enhancing glutamatergic neuron excitability in the CA1 region, it was possible to effectively mitigate synaptic plasticity impairment and ameliorate postoperative cognitive dysfunction.ConclusionsThe decline in SIRT1/BDNF levels leading to changes in synaptic plasticity and neuronal excitability in older mice could be a significant factor contributing to cognitive impairment after anesthesia/surgery.Graphical

Screw Position Following Percutaneous Versus Mini-Open Intramedullary Retrograde Screw Fixation of Metacarpal Fractures.

Metacarpal fracture fixation using the retrograde intramedullary screw technique can be performed through two different approaches. The mini-open approach requires greater soft tissue dissection but allows for direct visualization of the metacarpal head compared with the percutaneous approach. Our aim was to determine which approach resulted in optimal screw position. Eighty-one consecutive patients that underwent intramedullary screw fixation for metacarpal fractures from 2016 to 2021 were identified. Patients were treated by 4 fellowship-trained orthopedic hand surgeons who employed the mini-open or percutaneous approach. Postoperative radiographs were reviewed for screw position. A total of 81 patients (41 mini-open, 40 percutaneous) were included in this study. There were no significant differences between the two groups in age, sex, hand dominance, or affected digit. Postoperative screw position at first postoperative visit was not significantly different between the two groups on anteroposterior or lateral radiographs. Postoperative screw position is not significantly different between the mini-open and percutaneous approaches for intramedullary screw fixation of metacarpal fractures. Level III, therapeutic.

Outcome of Titanium Elastic Nailing System in Diaphyseal Femoral Fractures of Children in the Age Group of 4-12 years

Background: Femoral shaft fractures are the most common major pediatric injuries treated by orthopedic surgeons. Management of femoral diaphyseal fracture in the age group of 4-12 years is controversial. The purpose of this study is to demonstrate the effectiveness of intramedullary fixation of femoral shaft fractures by using Titanium Elastic Nailing System (TENS). Methodology: Twenty-six (26) children in the range of 4-12 years with recent (&lt;3 days) femoral shaft fracture (24 closed, 02 Grade-I compound) were stabilized with Titanium Elastic Nail (TEN), between January 2019 and June 2022 in Eastern Medical College Hospital, Cumilla and Cumilla Trauma Centre. The diameter of the individual nail was selected as per Flynn’s formula and the results were evaluated by Flynn’s criteria. All patients were followed radiologically as well as clinically until fractures healed and for any complications. Results: Among the twenty-six (26) cases 18 were boys and 8 were girls. Twenty-three (23) cases were managed by closed reduction while three (3) cases required open reduction. The time duration of surgery ranged 20-45 minutes. The hospital stay ranged between 5 to 8 days (mean 6.5 days). The mean duration of follow-up was 21 months (range: 3 - 39 months). All fractures were radiologically united at 8-12 weeks (mean 10 weeks) and full weight bearing was possible in a meantime of 9.5 weeks. According to Flynn’s criteria, excellent results were found in 24 (92.3%) cases and satisfactory in 2 (7.7%) cases. Limb lengthening was noticed in 6 cases and rotational mal alignment was seen in 1 case. Conclusion: Intramedullary fixation with Titanium Elastic Nail may be the preferred method for the treatment of femoral fractures in children aged 4-12 years. As it is a safe, minimally invasive, surgeon-friendly technique and shows very good functional and cosmetic results. Eastern Med Coll J. July 2023; 8 (2): 1-6

Comparison Between Intramedullary Nail and Percutaneous Pin Fixation in Proximal Phalanx Fractures.

Percutaneous pinning has been the predominant technique for fixation of proximal phalanx fractures, but stiffness is a reported complication. The introduction of intramedullary (IM) nail fixation of proximal phalanx fractures provides a stronger biomechanical fixation for amenable fracture patterns with the added benefit of not tethering the soft tissue. The goal of this study was to compare the surgical outcomes of IM nail and percutaneous pin fixation in isolated proximal phalanx fractures. A retrospective review was performed at our institution between the years 2018 and 2022 for patients treated for proximal phalanx fractures. Patients that underwent fixation with IM nails or percutaneous fixation for isolated extraarticular proximal phalanx fractures were included. Patients were excluded if they had concomitant hand fractures, tendon injury, or intraarticular extension. A total of 50 patients were included in this study. Twenty-eight patients received percutaneous pin fixation, and 22 patients underwent IM nail or screw fixation. There was no significant difference in injury patterns or demographics between these two groups. Patients that underwent IM nail fixation had a significantly quicker return to active motion, shorter duration of orthosis treatment, and fewer occupational therapy visits. In addition, patients in the IM fixation group had significantly improved range of motion (ROM) at 6 weeks postoperatively. This study demonstrates that patients receiving percutaneous pin or IM nail fixation have equivocal union and complication rates. The IM nail fixation group was able to have quicker return to mobilization, fewer required occupational therapy visits, and improved early ROM.

Intramedullary Compression Screw Fixation for Middle Phalangeal Fractures

This study aimed to evaluate short- and medium-term clinical and patient-reported outcomes of intramedullary compression screw fixation for extra-articular middle phalangeal fractures. A retrospective study was performed on a series of 20 patients (with a total of 23 fractured digits) who underwent fixation of middle phalangeal fractures between January 2020 and March 2023. The results from this cohort were compared against those for plate and K-wire fixation in the literature. Total active motion was 246°; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score was 4.9; verbal numerical pain score was 1.1 of 10; mean time for return to work was 62.5 days; and a single complication was noted in the entire cohort. Intramedullary screw fixation is a viable option in the treatment of extra-articular middle phalangeal fractures. It offers a favorable postoperative range of motion, good duration for return to function, excellent rates of complication, and low pain scores. Therapeutic IV.

Intramedullary Nailing Technique for Proximal Humeral Fractures Using a Straight Antegrade Nail with Locking Tuberosity Fixation.

Intramedullary straight nail fixation of proximal humeral fractures using a locking mechanism provides advantages compared with plating, including (1) less soft-tissue dissection, which preserves periosteal blood supply and soft-tissue attachments; (2) improved construct stability for comminuted fractures or osteopenic bone; and (3) shorter operative time for simpler fractures. The patient is placed in the beach-chair position with the head of the bed elevated approximately 45°. The fracture is reduced with use of closed or percutaneous methods, ideally, or with an open approach if required. Temporary fragment fixation with percutaneous Kirschner wires can be utilized. A 1-cm incision is made just anterior to the acromioclavicular joint, overlying the zenith of the humeral head and in line with the diaphysis. A guide-pin is then placed through this incision and is verified to be centrally located and in line with the humeral diaphysis on fluoroscopic views. The guide-pin is advanced into the diaphysis. A cannulated 9-mm reamer is inserted over the guide-pin to create a starting position. The nail is then inserted, with adequate fragment reduction maintained until the proximal nail portion is buried under the subchondral humeral head. The proximal screw trajectory and alignment are checked fluoroscopically. The proximal locking screws are pre-drilled and inserted first using percutaneous drill sleeves through the radiolucent targeting jig. The screw is inserted through the guide and is advanced into the nail until appropriately seated. This process is then repeated for the other proximal screws as necessary. Finally, the distal diaphyseal screws are pre-drilled and inserted in a similar percutaneous fashion using the jig, and the jig is removed. Final orthogonal images are obtained. Copious irrigation of the incisions is performed and they are closed and dressed with a sterile dressing. The operative arm is placed in an abduction sling. Alternative treatment options for proximal humeral fractures include nonoperative treatment with use of a sling, percutaneous reduction and internal fixation with Kirschner wires, open reduction and internal fixation with a locking plate and screw construct, hemiarthroplasty, and anatomic or reverse total shoulder arthroplasty1. The presently described technique for proximal humeral fracture fixation using a straight, antegrade, locking nail allows for minimal soft-tissue disruption, preserving vascularity and soft-tissue support and achieving angularly stable fixation in often osteopenic bone. The superior and in-line entry point avoids complications of rotator cuff injury and/or subacromial impingement. The proximal locking screws avoid complications of screw penetration or migration. This technique is appropriate for surgically indicated Neer 2-, 3-, and 4-part humeral fractures, including in elderly patients, when the humeral head fragment remains viable1-5. Based on available Level-III and IV evidence using this technique, patients should expect recovered motion and the ability to perform daily activities independently, with a mean active elevation of 132° to 136°1,4,6, external rotation of 37° to 52°1,4,6, and internal rotation to L31. Pain scores improved significantly from preoperatively to postoperatively, with a mean pain score of 1.4 on the visual analogue scale3,4,6. Patient-reported outcomes were good to excellent, with Single Assessment Numerical Evaluation (SANE) scores of 80% to 81%1,6, mean Constant scores from 71 to 811,3,4,6, and high rates of patient satisfaction (97% satisfied or very satisfied)4. Studies also demonstrated good to excellent fracture healing, with no tuberosity migration and low rates of nonunion (0% to 5%)1,6 and humeral head necrosis (0% to 4%)1,4. Revision rates ranged from 10.5% to 16.7%4,6. The starting position of the guide-pin must be central and at the zenith of the humeral head on the anteroposterior Grashey and the scapular Y views, and the guide-pin must be aligned with the diaphysis prior to advancing it.Failure to bluntly dissect the percutaneous incisions risks injury to the axillary nerve.Verify correct version of the nail prior to drilling any screws, to avoid incorrect version and potential loss of functional rotation. ABD = abductionAP = anteroposteriorCT = computed tomographyER = external rotationFF = forward flexion (forward elevation)IR = internal rotationSANE = Single Assessment Numerical EvaluationSSV = Subjective Shoulder ValueVAS = Visual Analogue Scale.

Outcomes and Complications of Intramedullary Metacarpal Fixation.

Metacarpal fractures are common orthopedic injuries with potentially debilitating outcomes. Ideal surgical treatment remains a topic of debate, with intramedullary fixation becoming popular as a technique to allow for earlier mobilization with few reported complications. The aim of this study was to report observed outcomes and complications of intramedullary metacarpal fixation using the ExsoMed INnate metacarpal nail. A retrospective chart review of 37 patients with 44 metacarpals treated with the ExsoMed INnate between July 2020 and December 2021 by a single fellowship-trained hand surgeon at a single level 1 trauma center was performed. Variables recorded included both patient and injury demographics, surgical complications, and postoperative outcomes. We also measured metacarpal isthmus diameter of the second to fifth metacarpals on all patients to determine the intramedullary canal diameter to assist in implant size selection. Average follow-up was 5.84 weeks with average time to radiographic healing of 5.5 weeks, and time to full activity 6.32 weeks. The mean postsurgical active total arc of motion was 250°, while passive total arc of motion was 259.74°. A total of 10 complications (22%) were identified, including 4 bent screws which occurred as a result of a punching event postoperatively. Intramedullary fixation of metacarpal fractures using the ExsoMed INnate metacarpal nail has shown to preserve range of motion and quick return to full activity, with a low rate of major complications. Our study highlights the potential major complication of the bent intramedullary screw and its association with an initial punching mechanism.

Augmenting locking plate with autologous bone graft for the treatment of nonunion of long bone fracture in the lower extremity with retaining of the original intramedullary nail

To explore clinical effect of attaching locking plate with bone grafting based on retaining the original intramedullary nail in treating non-union after intramedullary nail fixation of long shaft fractures of lower limbs. A retrospective study was conducted on 20 patients treated with non-union fractures after intramedullary nailing of long shaft fractures of lower limbs from June 2015 to June 2020. All patients were treated with the original intramedullary nailing and bone grafting from the iliac bone, and were underwent open reduction plate internal fixation and bone grafting for old fractures. Among them, 14 were males and 6 were females, aged from 35 to 56 years old with an average of (42.2±9.6) years old. Nine patients were femoral shaft fracture and 11 patients were tibial shaft fracture. According to characteristics of fracture end nonunion, 6 patients were stable/atrophic, 9 patients were unstable/large, and 5 patients were unstable/atrophic. The nonunion time ranged from 8 to 12 months with an average of(9.8±2.0) months after the initial surgery. Visual analogue scale (VAS), knee range of motion, bone healing time, complications and fracture-end healing were recorded before and at the latest follow-up. All patients were followed up for 18 to 48 months with an average of (36.3±10.5) months. The incision of all patients were healed at stageⅠwithout complications such as infection or internal fixation ruptur. Healing time of femur and tibia was (8.5±2.6) months and (9.5±2.2) months. Knee joint motion increased from preoperative (101.05±8.98) ° to postoperative (139.35±8.78) ° at the latest follow-up (t=-12.845, P<0.001). VAS decreased from preoperative (5.15±1.72) to postoperative (0.75±0.96) at the latest follow-up (t=11.186, P<0.001). On the basis of retaining the original intramedullary nail, the addition of locking plate internal fixation and autogenous iliac bone grafting have advantages of simple operation, less trauma, fewer complications and high fracture healing rate. It is one of the effective surgical schemes for the treatment of nonunion after intramedullary nail fixation of long bone fracture of lower extremity.

Intramedullary nail fixation of fibular fractures in combination with extra-articular distal tibial fractures (AO/OTA 43A): a single-center retrospective study.

Treatment of fibular fractures associated with extra-articular distal tibia fractures is technically challenging and the purpose of this study was to evaluate the use of intramedullary nail fixation of fibular fractures when associated with this fracture. Between January 2018 and December 2021, 33 patients presenting extra-articular distal tibia fractures and fibular fractures (AO/OTA 43A) were treated. Clinical and radiological data were collected during routine postoperative follow-ups. Thirty-one patients were monitored for a period of time ranging from 12 to 23 months, with an average follow-up of 17.5 ± 3.3 months. Fibular bone union took an average of 3.6 ± 0.9 months. At the last follow-up, the average fibular alignment and postoperative ankle talocrural angles were 1.8° and 9.1°, respectively. No detectable radiographic rotational malalignment and serious complications related to the fibular incision was observed. The average AOFAS and OMAS scores at the most recent follow-up were 88.3 ± 6.2 and 87.4 ± 6.0, respectively. Intramedullary nail fixation worked well to keep the fibula in place in fibular fractures connected to extra-articular distal tibia fractures.

Single-Use Reamer Shafts for Intramedullary Nail Fixation: An Addressable Source of Extraneous Cost and Medical Waste in Orthopaedic Surgery.

To analyze the impact of switching from single-use reamer shafts to reusable reamer shafts for intramedullary nail fixation (IMN) of femur and tibia fractures at a single level-one trauma center, in terms of cost, metal waste, and infection rates. Retrospective comparison study. Level one trauma centerPatients/Participants: Patients with operative femur and tibia fractures treated before and after adoption of a reusable reamer shaft. Reamed IMN fixation. Reductions in cost ($292 per shaft) and metal waste (0.44 pounds (lbs) per reamer shaft; reamer shaft failure (breakage and/or incarceration); superficial and deep infections. A single surgeon treated 125 and 135 fractures before and after adoption of a reusable reamer shaft. No reamer shaft failures were identified. The before and after groups did not differ in age, OTA/AO classification, or infection rates. By adopting reusable reamer shafts the surgeon avoided an estimated 54 single-use reamer shafts per year for an estimated cost and metal waste savings per year of $15,643 USD and 24 lbs. Over the same time period that the surgeon switched to using reusable reamer shafts, a total of 283 single-use reamer shafts were utilized by 12 surgeons in the same department. If the entire department had adopted reusable reamer shafts during that time period an estimated 164 reamer shafts per year would have been avoided for a total cost and metal waste savings per year of $47,763 USD and 72 lbs. Single-use reamer shafts represent an easily addressable source of extraneous cost and metal waste in orthopaedic surgery. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

History and Evolution of Hip Design to Decrease Failure.

The evolution of fracture fixation designs over the past 100 years is coupled with incredible advances in materials and manufacturing technology. Failures are unavoidable and should be evaluated from the perspective of refining our technology and technique to improve patient outcomes. Failure after intramedullary fixation of hip fractures is multifactorial with contributions from an unsuccessful surgery, some preventable, some unavoidable, and rarely, design and manufacturing errors. However, whenever implants are disseminated to large population groups with variable individual anatomy, physiology, and associated comorbidities, unexpected and unpredicted weaknesses in the design and surgical technique will be discovered. Surgeons have multiple choices for nail selection with specific and critical technical requirements. The surgeon should evaluate each patient individually and determine the treatment based on patient anatomy and morphology of the fracture. The surgical approach should be modified over time after deciding how best to improve surgical treatment based on the current scientific studies.

Closed Cephalomedullary Nail Fixation of a Reverse Oblique Subtrochanteric Femoral Fracture in the Lateral Position

In this case, Dr. Michael Weaver performs an intramedullary fixation of a reverse oblique trochanteric femoral fracture in a lateral position. Neutralizing the deforming forces on the proximal femur, this positioning allows the soft tissue to fall away and makes a direct reduction a bit easier, but taking x-rays in the lateral position is more challenging.