Intramedullary Nail Fixation Research Articles

Comparable Outcomes Between Native and Periprosthetic Fractures of the Distal Femur.

Despite the rising prevalence of arthroplasty and aging population, limited data exist regarding differences in periprosthetic fracture clinical outcomes compared with native counterparts. This study compares differences in hospital treatment, morbidity, and mortality associated with periprosthetic distal femur fractures at an urban level 1 trauma center. We retrospectively reviewed all adult AO/OTA type 33 fractures (526) that presented to our institution between 2009 and 2018. In total, 54 native and 54 periprosthetic fractures were matched by age and gender. We recorded demographics, operative measures, length of stay (LOS), discharge disposition, and mortality. We used McNemar's and paired t-tests for analysis where appropriate (p < 0.05) (IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY; IBM Corp.). The average age at injury was 74 years ± 12 (native) compared with 73 years ± 12 (periprosthetic). After 1:1 matching, the groups had similar body mass index (31.01 vs. 32.98, p = 0.966 for native and periprosthetic, respectively) and mechanisms of injury with 38 native and 44 periprosthetic (p = 0.198) fractures from low-energy falls. Both groups had 51/54 fractures managed with open reduction internal fixation with a locking plate. The remaining were managed via amputation or intramedullary nail fixation. Mean operative time (144 minutes (±64) vs. 132 minutes (±62), p = 0.96) and estimated blood loss (319 mL (±362) vs. 289 mL (±231), p = 0.44) were comparable between the native and periprosthetic groups, respectively. LOS: 9 days ± 7 (native) versus 7 days ± 5 (periprosthetic, p = 0.31); discharge disposition (to skilled nursing facility/rehab): n = 47 (native) versus n = 43 (periprosthetic, p = 0.61); and mortality: n = 6 (native) versus n = 8 (periprosthetic, p = 0.55). No significant differences were observed. We found no statistical differences in morbidity and mortality in periprosthetic distal femur fractures treated over 10 years at a level 1 trauma center. Native and periprosthetic AO/OTA type 33 distal femur fractures are serious injuries with similar outcomes at a level 1 trauma center.

Outcomes after primary intramedullary nail fixation of open tibial and femoral fractures in low resource settings.

Open fractures are unique in the urgency they impart to the injury and the therapeutic challenge they pose. Non-union and infection are among the major concerns. Open tibial and femoral shaft fractures are among the commonest orthopaedic urgencies. Primary intramedullary (IM) nailing requires a skillset and knowledge of the principles of open fracture management and also a well-equipped operating room with the necessary implants and instruments. In a low resource setting, one or more of these prerequisites may not be met, and the outcome may thus be affected similarly. The objective of this study was to study these outcomes. We prospectively studied primary IM nailing of open 1, 2 and 3A tibial and femoral fractures done in our hospital, in a simple non-modular operating room without an image intensifier. There were 106 fractures in 104 patients: 93 tibial and 13 femoral. The mean time from injury to surgical debridement was 19.6h. Mean duration of antibiotics therapy was 4.3days, and the mean duration of hospital stay was 4.1days. All patients were followed up to union. Mean time to radiographic union was 6.1months for the tibia and 5.7months for the femur. Non-union was seen in 4 tibial and 1 femoral fractures. There were 3 superficial infections but no deep infection. The outcomes were comparable to, and in some cases better than, those found in existing literature. We conclude that primary IM nailing in open long bone fractures can be performed in austere environments with good success, in expert hands if the principles are adhered to.

Short term outcome of Gustilo Anderson open type 3A mid shaft tibia fractures using intramedullary interlocking nail and external fixator

Aim: The purpose of the present study is to assess the outcome of treating Gustilo Anderson open Type 3A mid shaft tibia fracture with intramedullary interlocking nail as well as external fixator. Methodology: In this prospective cohort study, adult patients (≥18 years-old) with Gustilo 3A open tibia shaft fractures treated by either intramedullary nail or external fixation (EF) were involved. This study was directed for a period of twelve months from March 2021 to February 2022. After registration, patients were followed-up at 2, 6, 10, 14, and 18 weeks postoperatively. At these appointments, degree of callus formation at fracture site and surgical problems (e.g. infection, limb length discrepancy, malalignment) were assessed. Results: Out of 50 patients registered in the study, 26 were treated by IM nail and 24 by external fixation. Twenty-four patients (92.3%) in the IM nail group and 6 (25%) in the external fixation group had callus formation by the 10th week. The mean times to callus formation in the IM nail group and external fixation group were 8.2±2.6 weeks and 14.7±3.3 weeks, individually (p=0.000). Two (7.7%) patients in the IM nail group and 3 (12.5%) in the external fixation group developed infection (p=0.661).

Comparable outcomes with intramedullary nail and plate constructs for Schatzker VI tibial plateau fractures.

Outcomes data of intramedullary nail fixation (IMN) constructs for complex Schatzker VI tibial plateau fractures are scant in the literature. This study compares the clinical and radiographic outcomes of IMN, dual plate, and single plate constructs for Schatzker IV tibial plateau fractures. Retrospective cohort study of sixty-two patients at a University-based Level 1 trauma center who underwent open reduction internal fixation for Schatzker VI tibial plateau fracture. Constructs evaluated were IMN (with or without raft screws), dual plating, and single plating. Demographic, clinical, and radiographic outcomes were recorded. All fractures were additionally classified based on the OTA classification for sub analyses. Mean follow-up was 13.2 (SD 13.3) months. Predictors of construct selection and outcomes were evaluated with bivariate logistic regression. Outcomes were compared between groups with independent samples t-tests and Chi Square tests. No significant demographic differences were found between IMN, dual plate or single plate construct cohorts. There was a higher proportion of open fractures within the IMN construct group versus the dual plate cohort (21.1% vs 3.6%). No statistically significant differences in radiographic outcomes were observed between cohort groups except for small but statistically significant differences in condylar width (CW) ratio change and tibial slope; when fracture cohorts were sub analyzed by specific OTA classification, there were no significant differences in any radiographic outcomes. There was a significant difference between the ratio of OTA 41C1, C2 and C3 fractures regarding treatment allocation (p = 0.004), favoring dual plate fixation for OTA 41C3 fractures. There were no significant differences found between treatment cohorts in terms of all cause complications (p > 0.05). IMN and single plate constructs were utilized when posteromedial condyle fractures were nondisplaced or minimally displaced. Intramedullary nail fixation with or without supplemental raft screws produced similar short-term clinical and radiographic results compared to dual and single plate constructs among patients with Schatzker VI fracture types, regardless of OTA classification. Level of Evidence Level III retrospective cohort.

Fracture Fixation Strength in Metacarpal Plating Versus Intramedullary Nailing Using a 3-Point Bending Model: A Cadaveric, Biomechanical Study

The purpose of our study was to evaluate the ultimate load to failure for 2 metacarpal fracture fixation strategies, plating versus intramedullary nailing, and then compare them to the native metacarpal. Our hypothesis was that the intramedullary nail after fracture fixation would more closely restore the native strength of the metacarpal when compared to plate fixation. Matched pairs of cadaveric hands (age range, 19-49; 5 men and 6 women) were dissected to produce 88 intact and equally distributed metacarpals (little, ring, middle, and index fingers). The metacarpals were then randomly selected to undergo either plate fixation or intramedullary nail fixation. A 3-point bending model was used to test the native metacarpal strength to the point of fracture and, subsequently, the fracture fixation construct. The data were then compared against the native metacarpal for normalized load to failure, normalized displacement, and stiffness. The normalized maximum force (ratio of fixation:native) for the intramedullary nail specimens was significantly closer to normal than for the plated specimens for the little, middle, and index fingers, as well as for all metacarpals combined. We did not detect a difference in maximum force for the ring finger. When compared to plate fixation, metacarpal intramedullary nailing more closely restores the ultimate load to failure of the native metacarpal after midshaft fracture. For metacarpal fracture patterns amenable to intramedullary screw fixation, an intramedullary nail has biomechanical properties that are superior to a plate and screws in a 3-point bending model.

Dynamic hip screw versus intramedullary nailing for the treatment of A1 intertrochanteric fractures: A retrospective, comparative study and cost analysis.

Objectives This study aims to compare sliding hip screw and intramedullary nail perioperative results and costs in two-part femoral fractures.Patients and methods Between January 2015 and December 2019, a total of 85 patients (70 males, 15 females; mean age: 85.6±9.5 years; range, 33 to 99 years) who were treated for intertrochanteric two-part femoral fractures were retrospectively analyzed. The patients were stratified and divided into two groups according to type of implant used for surgical fixation: one group treated with intramedullary proximal femoral nail (EBA) and the other with sliding hip screw (DHS). Comorbidity, hemoglobin level (Hb), hematocrit (hct) level, number of transfusions, and days of hospitalization details were evaluated. Postoperative X-rays were analyzed to assess the quality of reduction and to identify non-union, malunion, mechanical failures, and heterotopic ossifications. The modified Harris Hip Score, fracture mobility score, and Parker Mobility Score were calculated. Cost analysis considered the orthopedic device, operating room, transfusion, and hospital costs for the primary hospital stay.Results Of the patients, 44 were treated with DHS and 41 were treated with EBA nail by a single surgeon. No significant differences were found in the baseline demographic data. There was a significant increased operative time (p<0.001) and decreased fluoroscopy X-ray exposure time (p=0.031) in the subgroup of patients who underwent DHS fixation. The patients who underwent EBA nail fixation had a significantly higher transfusion rate during hospitalization (p=0.001) and a significantly lower Hb level and hct level on postoperative Day 1 and Day 3 (p<0.05). There were no significant differences in the clinical and functional scores, radiographic outcomes and mortality (p>0.05). The patients who underwent intramedullary nail fixation had higher costs.Conclusion Sliding hip screws showed decreased postoperative anemization, lower transfusion rates, and similar clinical outcomes compared to the intramedullary nail for two-part femoral fractures. Sliding hip screws should be preferred for A1 intertrochanteric fractures.

Incidence of secondary interventions after early spica casting for diaphyseal femur fractures in young children.

Background:Children aged 6 months to 5 years with diaphyseal femur fractures are typically treated with spica casting, as recommended by the American Association of Orthopaedic Surgeons clinical practice guideline. We aimed to determine the incidence of secondary interventions after early spica casting for femur fractures in children aged 6 years or less.Methods:This was a retrospective cohort study of patients aged 6 years or less with diaphyseal femur fractures treated with early spica casting at a single Canadian tertiary care, level 1 trauma pediatric centre between January 2005 and May 2015.Results:A total of 246 patients were included (190 boys [77.2%] and 56 girls [22.8%] with a mean age of 2.28 yr [standard deviation (SD) 1.35 yr]). Nine patients (3.7%) required early secondary interventions (cast wedging in 8 and flexible intramedullary nail fixation in 1). At last follow-up, 51 patients (20.7%) had clinically measurable limb length discrepancy (LLD) (mean 9.4 mm [SD 3–25 mm]), and 1 patient (0.4%) had mild clinical valgus deformity. Older, heavier patients with initial fracture shortening of 20 mm or more had a higher likelihood of developing a clinically measurable LLD. No patient required surgical intervention after fracture union to correct acquired LLD or angular deformity.Conclusion:Early spica casting for diaphyseal femoral fractures in children aged 6 years or younger had a low rate of complications and return to the operating room, Although 21% of patients had a clinically measurable LLD at last follow-up, no patient required secondary intervention after fracture union to correct acquired LLD or angular deformity. These findings have relevance for the Canadian health care system, especially during the COVID-19 pandemic.

Percutaneous Femoral Derotational Osteotomy in the Skeletally Immature Patient.

This is a percutaneous procedure that involves creation of femoral drill holes at the osteotomy site prior to reaming the canal4. External fixator pins are placed proximal and distal to the osteotomy site prior to completing the osteotomy. These pins are derotational markers for the surgeon and act to hold the correction with use of an external fixator while the interlocking screws are being placed. The pins are placed at a degree of divergence that is equal to the degree of intended derotation so that the pins will become parallel in the axial plane following derotation of the femur. The percutaneous osteotomy is then completed with use of an osteotome, and the trochanteric entry nail is passed across the osteotomy site while correcting rotation. Once rotation is fully corrected and the pins are parallel, the external fixator is placed to hold the rotation and interlocking screws are placed. Nonoperative alternatives to this procedure include physical therapy for gait training and strengthening as well as modalities to address hip and knee pain that may be associated with version abnormalities. Although physical therapy is often prescribed, it must be noted that excess version is a fixed osseous structural pathology that therapy cannot address. Additionally, compensatory mechanisms that may be taught to improve gait and walk with a neutral foot progression angle may exacerbate hip or knee pathology as a result of the underlying version abnormality. Surgical alternatives include derotational osteotomies of the proximal or distal aspects of the femur with use of an open technique with plate fixation, as opposed to an intramedullary nail following percutaneous diaphyseal osteotomy as presented here1. Additionally, an open technique with intramedullary nail fixation may be performed5. Excessive anteversion can cause both hip and knee symptoms, including hip pain, instability, labral and psoas pathology, and patellofemoral instability6. Excessive retroversion can cause impingement between the femoral neck and acetabulum, which results in pathology of the labrum and articular cartilage7. Additionally, abnormalities of version often lead to gait disturbances with frequent tripping and difficulty running8. Children with femoral version abnormalities have limited remodeling potential after age 83. A derotational osteotomy may be performed to correct symptomatic excess femoral version in an older child or adolescent. The patient may be weight-bearing as tolerated with upper-extremity assistance immediately following the procedure. The osteotomy typically heals between 6 and 12 weeks, and the patient may return to activities as tolerated once the osteotomy is healed. Gordon et al. described the outcomes of a similar technique for femoral derotational osteotomy in skeletally immature patients with excessive femoral anteversion3. The study retrospectively reviewed the results of the technique in 13 patients and 21 limbs at a minimum follow-up of 1 year. All patients complained of tripping and gait abnormalities preoperatively. All patients noted gait improvement, and no intraoperative or postoperative complications were reported. Healing of the osteotomy occurred at a mean of 6 weeks postoperatively. No patient developed osteonecrosis. We routinely remove hardware in skeletally immature patients approximately 1 year postoperatively. Complications are rare and include hardware irritation, infection, nonunion, and neurovascular injury. Preoperative planning is critical for this procedure, and the surgeon should know the intended degree of derotation, the location of the osteotomy relative to the greater trochanter, the length of the nail, and the approximate diameter of the nail prior to entering the operating room.Percutaneous bicortical femoral drill holes are created at the site of the osteotomy prior to reaming to allow for egress of reamings and bone marrow elements at the osteotomy site, which serve as autograft and stimulate bone healing. Additionally, the drill holes provide ventilation to prevent excessive intramedullary pressure during reaming9-11.External fixator pins are placed proximal and distal to the osteotomy prior to completion of the osteotomy to allow for rotational assessment after completion of the osteotomy. Placing these pins bicortically so that they are secure in the bone and ensuring that the divergence is correct for the intended amount of derotation is critical in this procedure because once the osteotomy is complete, the pins are the only markers of rotation the surgeon has to guide the correction.An external fixator is helpful in holding the femur at the intended degree of derotation during placement of the interlocking screws. ROM = range of motionCT = computed tomographyMRI = magnetic resonance imagingAP = anteroposteriorGT = greater trochanterAV = anteversionER = external rotationIR = internal rotationA = anteriorP = posteriorM = medialL = lateralXR = X-rayProx = proximalEx fix = external fixatorWBAT = weight-bearing as toleratedBLE = bilateral lower extremitiesDVT = deep venous thrombosisPT = physical therapyppx = prophylaxisAVN = avascular necrosis (osteonecrosis).

Multicenter, retrospective comparison of implant survival, complications and cost between plate and screw and intramedullary nail fixation for metastatic lesions of the diaphyseal humerus.

The humerus is a common site of metastatic disease that can be fixated with either plate and screw or intramedullary nail (IMN) constructs. A multicenter retrospective comparison study was undertaken to compare implant survival, complication rate and cost between the two constructs. No prior studies have included a cost comparison. Databases of two academic practices were queried retrospectively to identify patients with metastases of the humerus. Inclusion criteria were a lesion in the proximal metaphysis to distal diaphysis and amenable to both implant options with available cost data. Follow-up was at least 6 months barring death or discharge to hospice sooner. Demographic, clinical and outcome data was recorded. Costs were estimated based on contract pricing. Operating room (OR) costs were estimated using per minute OR costs proposed by other investigators. One hundred and one humeri in 96 patients were included (72 plates and 29 nails). The most common malignancies were renal cell, myeloma and lung. Half presented with a displaced fracture. Demographics were similar in both groups. Lesions were larger in the plate group. Surgical times were longer in the plate group, 146 vs. 75 min, P<0.001. Estimated blood loss (EBL) was higher in the plate group, 510 vs. 221 mL, P<0.001. A trend toward increased failure was seen in the plate group, 12.5% vs. 0% (P=0.056). The most common complications in the plate group were pain, stiffness and swelling compared to pain, refracture and PE in the nail group. Local disease progression was equivalent. Implant costs were higher in the IMN group ($2,753 vs. $1,553, P<0.001), while OR costs were lower ($2,349 vs. $4,395, P<0.001). Overall cost of implantation was lower in the IMN group ($5,102 vs. $5,949, P=0.005). IMN of metastases of the humerus offers a faster, potentially more durable construct with lower blood loss, faster OR times and decreased cost of implantation.

Combined Medial Plate and Intramedullary Nailing for the Fixation of Extra-Articular Proximal Tibial Fractures: a Biomechanics Study.

Purpose: The extra-articular proximal tibial fractures continue to have high malunion rates despite development in intramedullary nailing (IMN) technology. Combined plate and IMN fixation can increase mechanical stability. The purpose of this study was to investigate combined plate and IMN for the treatment of extra-articular proximal tibial fracture using a biomechanical model. Methods: A 10-mm defective osteotomy was created in the fourth-generation composite tibia to simulate extra-articular proximal tibial fractures (AO/OTA 41A2). The fractures were stabilized with IMN alone (IMN group), IMN with supplementary medial plate (M-IMN group), and IMN with supplementary lateral plate (L-IMN group). The biomechanical properties of each specimen were tested under axial compression loading, bending stress, and cyclic loading. The maximum displacement of the fragments and implant-bone construct failure was recorded. Results: The maximum displacement of the M-IMN group was significantly less than either the L-IMN or IMN group in both axial compression loading and bending stress (p < 0.05 for both comparisons). All specimens in the three groups survived in 10,000 cyclic loading without hardware deformation. The maximum stiffness of failure was similar between the M-IMN and L-IMN groups, but the IMN group was statistically lower than either the L-IMN or the IMN group (p < 0.05). Conclusion: The results indicated that combined medial plate and IMN fixation could effectively increase the mechanical stability of proximal tibial fractures.

Elastic Stable Intramedullary Nailing and Temporary External Fixation for the Treatment of Unstable Femoral Shaft Fractures in Children Aged 5-11 Years Old: A Retrospective Study of 28 Cases.

PurposeUnstable femoral shaft fractures (UFSFs) in children aged 5–11 years remain challenging due to their intrinsic instability. The aim of this study was to evaluate the clinical and radiographic outcomes of UFSF in children aged 5 to 11 years managed by the combined use of ESIN and temporary EF.MethodsChildren with UFSF (long oblique and comminuted) treated by ESIN and temporary EF were retrospectively reviewed. Sex, age at injury, side involved, type of fracture, presence or absence of associated lesions or neurovascular complications, type of treatment, time from trauma to surgery, duration of surgery, radiation exposure and length of postoperative immobilization were collected from the medical charts. Radiological and functional outcomes were evaluated according to Beaty's and Flynn's criteria, respectively.ResultsA total of 28 consecutive patients with closed or open (Gustilo type I or II) UFSF were reviewed (18 boys and 10 girls). The mean age at injury was 8.7 ± 1.6 years (range, 5–11); the average weight was 38.1 ± 7.6 kg (range, 26–55). The mean hospital stay was 3.7 ± 1.4 days (range, 2–7), and the mean time to EF and ESIN removal was 6.5 ± 1.1 weeks (range, 4–8) and 9.4 ± 1.6 months (range, 6–12), respectively. Twenty-seven out of 28 patients had excellent radiographic outcomes according to Beaty's criteria, and 24/28 had excellent functional outcomes according to Flynn's criteria. Overall, 4 complications (14.3%) were recorded. No statistically significant correlation was found between complication rates and sex, age, weight or fracture characteristics (P < 0.05).ConclusionsThe combined use of ESIN and temporary EF provides good clinical and radiological outcomes in children with UFSF aged between 5 and 11 years, with a reduced complication rate.

Network Meta-Analysis of Open Reduction Internal Fixation, Intramedullary Nail Fixation, and Distal Femoral Replacement for Periprosthetic Distal Femur Fractures

Background: Although open reduction internal fixation (ORIF) with periarticular locking plates, retrograde intramedullary nail (IMN) fixation, and distal femoral replacement (DFR) have been widely used for the treatment of periprosthetic distal femur fractures (PPDFF), it remains unclear which one may be an optimal surgical strategy.Objective: This network meta-analysis aimed to determine the optimal surgical strategy for PPDFF from ORIF, IMN, and DFR by evaluating major complication rates and revision rates.Patients and Methods: We identified eligible studies by performing an updated literature search in PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) and checking published meta-analyses. The methodological index for non-randomized studies (MINORS) was used to assess the methodological quality of eligible studies. Major complications and revision rates were defined as outcomes of interest. All statistical analyses were performed by ADDIS 1.4 software.Results: We included 17 eligible studies in the final analysis. Statistical analyses did not reveal significant differences when ORIF was compared with IMN and ORIF compared with DFR, and IMN compared with DFR in terms of two clinical outcomes. However, DFR achieved a beneficial trend in major complications [odds ratio (OR) = 1.34; 95% CrI = 0.48–3.80] and revision (OR = 1.64; 95% CrI = 0.68–4.38) rates compared with IMN. Ranking probabilities indicate that DFR has the highest probability of being the optimal option, followed by ORIF and IMN.Conclusion: There was no difference in major complications or reoperations between the three treatments. However, ORIF with periarticular locking plates may be a preferred alternative option because DFR is limited by the high cost. Moreover, our study highlights the need for future prospective trials evaluating the outcomes of these three surgical strategies.

Corrective osteotomy for complex tibial deformity in a patient with hereditary vitamin D-resistant hypophosphatemic rickets (HVDRR) using CT-based navigation system and 3D printed osteotomy model

Planning a three-dimensional (3D) osteotomy using computed tomography (CT) data is useful especially in cases with complex deformities. Furthermore, CT-based navigation system allows the preoperative virtual planning to be replicated in actual surgery. However, one disadvantage when using navigation systems is that when osteotomies are performed on tracker-attached bone, the bone fragments on the side that were cut away cannot be tracked. This is especially problematic when performing multiple osteotomies on bones with complex deformities. We solved this problem by creating a 3D printed bone model that can be referenced intraoperatively and used in combination with the navigation system. We applied these techniques to perform segmental corrective osteotomy for a complex tibial deformity with intramedullary nail (IMN) fixation case of hereditary vitamin D-resistant hypophosphatemic rickets (HVDRR) in an adult man. Due to the patient’s history of multiple surgeries, the affected tibia had a narrow and partially closed medullary canal. Therefore, we planned to use an IMN for correction and fixation of tibial deformity to protect the thin and stretched skin around the deformed tibia. With the assistance of CT-based navigation, we could perform an accurate three-dimensional tibial osteotomy. Moreover, we could perform accurate preparation of closed medullary canal for the IMN placement by referring to the 3D printed bone models. Six months after the operation, the bone union at the osteotomy sites was confirmed and the patient was able to return to his normal life and work.

Conservative Treatment of Closed and Gustilo Type-I Tibial Shaft Fracture

Background: As the tibia is a subcutaneous bone tibial shaft fractures are the common long-bone fractures, mostly closed and Gustilo Type-I. Various treatment methods including conservative treatment external fixation, intramedullary nailing and plate fixation have been suggested but none of these is considered the “gold slandered” for these injuries. Objective: The objective of this study is to evaluate the outcome of conservative treatment of closed and Gustilo Type-I tibial shaft fractures. Methods: A total of 43 fractures of the shaft of the tibia were treated with closed reduction and a long leg cast for eight to ten weeks followed by a PTB cast for another six to eight weeks from July 2018 to June 2021. One year follow up was done with 33 patients, ten months follow up with seven patients and three patients were lost to follow up. Results: All fractures united within six months of duration. Immediate post-reduction angulation was 2.52 degrees in the sagittal plane and 3.12 degrees in the coronal plane. The average final angulation was 4.45 degrees in the sagittal plane and 3.85 degrees in the coronal plane. The average limb length shortening was 5.4 mm. A full range of motion was gained compared to the normal side by six months of follow up. Conclusion: Closed Tibial shaft fractures can be treated conservatively with closed reduction and cast immobilization with many advantages over operative methods.

Tibiotalocalcaneal arthrodesis for the treatment of midfoot Charcot neuroarthropathy

Charcot neuroarthropathy of the foot and ankle is a destructive disorder resulting in severe and debilitating deformity. The goal of surgical reconstruction in Charcot neuroarthropathy is to create a stable, plantigrade foot that is amenable to bracing and offloading. Many reconstruction methods have been described in the literature including ostectomy of osseous prominences, realignment ostoeotmies, intramedullary midfoot beaming, plate fixation and external fixation. In this study we describe the use of tibiotalocalcaneal arthrodesis with intramedullary nail fixation for the treatment of midfoot Charcot neuroarthropathy in 12 consecutive patients. The mean age of our patient population was 61.33 years, mean BMI was 37.03 kg/m2, 9 patients were type II diabetics, 2 patients were type I diabetics and 1 patient had a diagnosis of idiopathic neuropathy without underlying diabetes mellitus (DM). The mean duration of DM diagnosis was 24.73 years. 9 patients within the study population had suffered from chronic or recurrent ulcerations secondary to osseous deformity that had failed conservative treatment and 3 patients had residual ulceration at the time of surgery. Fusion was observed in 10 of 12 patients within the study. All patients had a functional, plantigrade foot post-operatively. Overall, 5 patients are ambulating in custom diabetic shoes without assistive devices while the remaining patients are ambulating with assistive devices. The results of this study indicate that tibiotalocalcaneal arthrodesis with retrograde intramedullary nail fixation for midfoot Charcot neuroarthropathy is a reliable treatment option to provide a stable, plantigrade, braceable foot.

Comparison of Patient-Reported Outcomes After Suprapatellar Versus Infrapatellar Nailing Techniques for Tibial Shaft Fractures: A Systematic Review and Meta-analysis.

To compare patient-reported outcome measures (PROMs) between patients who underwent intramedullary nail (IMN) fixation for tibial shaft fractures using an infrapatellar (IP) or the newer suprapatellar (SP) approach. Secondary outcomes included fluoroscopic radiation exposure, operative time, and radiographic outcomes. A systematic literature search of the databases Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials Study Selection. Level I to III studies in which patients over the age of 18 years with acute tibial shaft fractures who underwent tibial IMN fixation using an IP or SP approach for fracture fixation were assessed for inclusion. Studies with a minimum of 10 patients in each cohort that reported on postoperative patient-reported outcomes with at least 6 months of follow-up were included for analysis. Twelve studies that reported PROMs and compared IP and SP intramedullary nailing of tibial shaft fractures were analyzed. This included 654 patients who underwent IP IMN fixation and 542 patients who underwent SP IMN fixation. A random-effects model for unadjusted/crude study estimates were pooled using inverse variance (IV) weighting for continuous variable analysis. This review found a significant improvement in PROM for patients with tibial shaft fractures when the SP IMN technique was used. In addition, there was a significant decrease in intraoperative fluoroscopy time consistent with other radiographic findings demonstrating improved start point accuracy and reduction with SP IMN fixation of tibial shaft fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cost-effectiveness analysis of routine follow-up for hip fracture patients after dynamic hip screw and intramedullary nail fixation

• Determining the appropriate outpatient management for patients following IM Nail or DHS for neck of femur fractures should be directed by clear objectives. • Routine post-operative surgical encounters with these patients rarely alter their clinical management. • We propose more selective follow-up protocols and adequately resourcing virtual alternatives. • The current outpatient hip fracture care pathway should be optimised to focus on comprehensive multidisciplinary treatment such as rehabilitation, fracture prevention and bone health optimisation. The rising number of hip fractures has incentivised several quality improvement initiatives aimed at improving outcomes. These include the national hip fracture audit and the best practice tariff. Whilst there is an established standard of care for inpatients, the optimal outpatient management of patients after hip fracture fixation remains undefined. We aim to evaluate the cost-effectiveness of routine surgical appointments and provide evidence to support an improved outpatient hip fracture care pathway that focuses on more comprehensive multidisciplinary treatment. This study retrospectively examined all patients who underwent either dynamic hip screw or intramedullary nail fixation for hip fragility fracture at our hospital over a 3-year period. Data was obtained from the Irish Hip Fracture Database (IHFD), the national integrated imaging system (NIMIS) and the medical charts. The number of outpatient appointments, postoperative radiographs and estimated cost of these patient encounters was examined. The rate of revision surgery as well as the type and timing of these interventions was also analysed. We included 272 patients. The mean number of inpatient and outpatient radiographs was 1.13 and 1.54 per patient respectively. There were 428 outpatient appointments scheduled, an average of 1.6 (SD 1.5) per patient. The median length of stay was 12 days (IQR 8-17). Only 16 (5.8%) patients had abnormal X-ray findings and only 8 (2.9%) patients underwent revision surgery. The majority (15/16, 94%) of patients with surgical complications presented with significant symptoms. There was a 13.1% DNA rate resulting in a cost to the health service of €1,400. The combined total cost of follow-up for all patients over the 3 year period was €92,252. Routine postoperative surgical encounters rarely alter a patient's management and contribute significantly to healthcare costs, resources and time loss for patients and their carers. We propose more selective follow-up protocols, adequately resourcing virtual alternatives and an improved outpatient hip fracture care pathway that focuses on comprehensive multidisciplinary treatment such as rehabilitation, fracture prevention and bone health optimisation.

Posterior hip fracture-dislocation associated with posterior wall fracture of the acetabulum and ipsilateral comminuted trochanteric fracture of the femur: A case report.

Introduction and importanceTraumatic posterior dislocation of the hip is often associated with fractures of the femoral head and posterior wall of the acetabulum. However, hip fracture-dislocation that includes the posterior wall of the acetabulum and the ipsilateral femoral trochanter is rare. There is no consensus on the bone that should be operated on first, the operative position, and the choice of implant for femoral fixation.Case presentationA 67-year-old man was brought to our emergency department after a 2-m fall. He was diagnosed with a hip fracture-dislocation associated with posterior wall acetabular fracture and ipsilateral femoral trochanteric fracture. Surgical reconstruction was performed with intramedullary nail (IMN) fixation of the femoral trochanteric lesion, followed by anatomically rigid acetabular fixation in the lateral decubitus position. At the 5-year follow-up after the injury, the patient showed good objective and subjective clinical outcomes.Clinical discussionFixing the femur first could allow an easier reduction and traction. The lateral decubitus position was useful, because fixation of the femur and the acetabulum could be performed without changing the position. When fixing the femoral trochanteric lesion, attention was paid to reduce the anteromedial cortex of the proximal fragment extramedullarly to the distal fragment to prevent complications such as cutout and implant breakage.ConclusionAnatomically rigid fixation of the posterior wall of the acetabulum secondary to IMN fixation of the femur, with anteromedial cortical support in the lateral decubitus position, could achieve good objective and subjective clinical outcomes.

Open Tibial Fracture Treatment in Argentina: Reoperation Rates Following Surgical Management.

Background:The purposes of the present study were (1) to characterize open tibial fractures and their treatment in trauma centers located across different regions of Argentina and (2) to evaluate the rates of and indications for reoperation after the surgical treatment of such fractures.Methods:This retrospective multicenter study evaluated open tibial fractures in Argentina that were operatively treated by experienced orthopaedic trauma surgeon-members of the Argentine Association of Orthopedic Trauma (AATO) between January 2015 and June 2020. Data were collected from 13 hospital databases; 8 hospitals were designated as “interior,” and 5 hospitals were designated as “exterior.” The study included 701 skeletally mature patients, all of whom had a minimum of 12 months of follow-up. Information was collected on patient demographics, injury pattern and mechanism, fracture classification, treatment modality, reoperation rates, time between definitive fixation and reoperation, and indications for reoperation.Results:Seventy-six percent of presenting injuries were the result of a high-energy mechanism. Intramedullary nailing represented the most common type of fixation (88%). One hundred and fifty patients (21%) required reoperation. Delayed union/nonunion was the most common indication for reoperation in patients who had been previously treated with intramedullary nail fixation (31%; 39 of 126), and infection was the most common indication for reoperation in patients who had been treated with plate fixation (43%; 3 of 7). The time between the injury and definitive fixation was significantly different between the interior and exterior trauma centers (13.8 versus 4.7 days; p < 0.001), as was the time between definitive fixation and reoperation (69.3 versus 25.2 days; p = 0.004). The reoperation rates for the interior and exterior trauma centers were similar (20% versus 24%; p = 0.2). Infection, delayed union/nonunion, and implant removal were the most common indications for reoperation across groups.Conclusions:An improved understanding of the factors that influence treatment may help to guide future areas for improvement, establish educational goals, and create additional nationwide guidelines for open tibial fracture treatment.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comments on “Successful results obtained in the treatment of adolescent forearm fractures with locked intramedullary nailing”—The need for a large multi-center study to compare locked intramedullary nailing, titanium elastic intramedullary nailing and plate fixation for treatment of adolescent forearm fractures

Comments on “Successful results obtained in the treatment of adolescent forearm fractures with locked intramedullary nailing”—The need for a large multi-center study to compare locked intramedullary nailing, titanium elastic intramedullary nailing and plate fixation for treatment of adolescent forearm fractures