Intramedullary Nailing Research Articles

Elastic stable intramedullary nailing in paediatric diaphyseal forearm fractures – a retrospective analysis of 201 cases

BackgroundForearm shaft fractures are common injuries, often caused by falling from a fully-upright position or falling off a bike. They can be treated nonoperatively or surgically with intramedullary nailing or plates. The method of choice for treating pediatric forearm shaft fractures is the application of elastic stable intramedullary nailing (ESIN)|. The aim of the study was to evaluate ESIN in pediatric patients with forearm shaft fractures based on radiological images, and determine the etiology and complication rate associated with the injury.MethodsThe study included 201 patients, 30.5% female 69.5% male, aged 1 to 17 years (mean 9.1 years; SD = 3.2), all had been diagnosed with a fracture of the forearm shaft and had been treated surgically with ESIN. In addition, all possessed a complete set of X-ray images and had attended a minimum six-month follow-up examination of the forearm. Axial alignment was evaluated retrospectively in the anatomical (AP) and lateral (LAT) positions. In total, 402 radiographs were examined. Of the injuries, 68% occurred during sports activity and 75% involved both the radius and the ulna.ResultsUnion was observed in all cases. Mean axial alignment values in AP and LAT X-ray or both the ulna and radius were satisfactory. Axial alignment values were not influenced significantly by age, type of surgery, type of fracture or etiology. Plaster cast application (9.8% of cases) significantly influenced radius axial alignment. The complication rate was 11.4% (n = 23). Significantly more complications were observed in patients receiving open reduction internal fixation (ORIF) (p = 0.0025).ConclusionThe ESIN technique is an effective treatment for forearm diaphyseal fractures in children, with good results regarding reduction and bone healing, indicated by x-ray.

Outcomes of Intramedullary Nailing Versus Plate Fixation in the Management of Humeral Shaft Fractures: A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to compare the outcomes of intramedullary nailing (IMN) and open reduction with internal fixation (ORIF) in treating traumatic humeral shaft fractures in adults (18 years and above). A comprehensive literature search was conducted in databases including PubMed, Google Scholar, Embase, and CochraneCentral Register of Controlled Trials (CENTRAL). The primary outcome was time to union, while secondary outcomes included non-union rates, incidences of iatrogenic radial nerve palsy, surgical site infections, and intra-operative comminution. Twenty-six studies, encompassing 1,674 patients (867 IMN, 807 ORIF), were included. IMN demonstrated a shorter time to union compared to ORIF (mean difference -1.06 (95% CI, -1.88 to -0.23)), with significant statistical heterogeneity (I² = 70%), and a mean difference of -2.14 (95% CI, -3.16 to -1.12) in the randomized controlled trial (RCT) subgroup analysis, which had no significant statistical heterogeneity. Both techniques had comparable non-union rates (risk ratio 0.34 (95% CI, 0.94 to 1.93)). IMN was associated with lower incidences of iatrogenic radial nerve palsy (risk ratio 0.48 (95% CI, 0.27 to 0.87)) and surgical site infections (risk ratio 0.44 (95% CI, 0.25 to 0.76)), but had a higher risk of intra-operative comminution (risk ratio 3.04 (95% CI, 1.24 to 7.44)). The studies exhibited significant heterogeneity and varying outcome measures, highlighting the need for cautious interpretation. IMN offers rapid fracture stabilization and minimal additional physiological insult, while ORIF remains preferable for achieving precise anatomical reduction. These findings highlight the importance of considering patient-specific factors and surgical expertise in selecting the appropriate fixation technique.

Forearm Fractures in Older Children and Adolescents: ORIF is Safer Than IMN With Equivalent Outcomes.

Greater understanding of the impact of skeletal maturity on outcomes is needed to guide operative treatment of diaphyseal forearm fractures in children and adolescents. The purpose of this study was to compare the complications and outcomes of pediatric diaphyseal forearm fractures treated with intramedullary nailing (IMN) or open reduction internal fixation (ORIF) and to identify a radiographic marker of skeletal maturity that will aid in selecting between treatment options. A retrospective review of patients aged 10 to 16 years treated operatively for diaphyseal forearm fractures was performed. Markers of skeletal maturity including the olecranon apophysis score, the presence of the thumb adductor sesamoid, and radial epiphyseal capping. Complications were graded with the modified Clavien-Dindo system. Outcomes were scored based on final postoperative range of motion combined with complication grade. A total of 260 patients were included: 163 treated with IMN, 97 treated with ORIF, mean age 12.7 years, 72% male. Among closed forearm fractures treated with IMN, open reduction was required in 45% (53/118). Patients treated with IMN had a higher complication rate than ORIF (27.0% vs. 9.3%, P<0.05), including when stratified by age. Complication rates were not impacted by greater skeletal maturity as indicated by the presence of thumb sesamoid or radial epiphyseal capping. There was no significant difference in outcomes between the ORIF and IMN groups. More skeletally immature patients, as identified by a lack of either the thumb adductor sesamoid or radial epiphyseal capping, had significantly better outcomes with ORIF than patients with greater maturity. Across all age groups and levels of skeletal maturity, ORIF had a significantly lower rates of complications compared with IMN with equivalent outcomes. More skeletally immature patients had significantly better outcomes with ORIF treatment when compared with older patients. The thumb adductor sesamoid, radial epiphyseal capping, and the olecranon apophysis score did not provide useful information to select between ORIF over IMN in this population. Level III-retrospective comparative study.

Open reduction and plate fixation of fractures of both bones in the forearm in Klippel-Trenaunay-Weber syndrome: a case report

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare disease characterized by vascular malformations, port-wine staining, and soft tissue and bone hypertrophy. Lesions occur in the lower extremities in 95% of cases, whereas only 5% occur in the upper extremities. Several case reports have described the treatment of fractures in the lower extremities in patients with KTWS. However, the risk of massive bleeding, bone deformity, and poor bone quality can lead to suboptimal surgical outcomes. No reports describing the treatment of forearm shaft fractures in KTWS could be found in the English-language literature. Intramedullary nailing is difficult due to the deformed bone and the risk of nonunion. Open reduction and internal fixation (ORIF) should be considered with caution in KTWS patients due to the risks of intraoperative bleeding and wound problems. The authors report that satisfactory results were obtained with ORIF after preoperative vascular embolization in a 60-year-old KTWS patient with fractures in both bones of the forearm.

One-Stage Tibiotalocalcaneal Arthrodesis for Severe Septic Destruction of the Ankle Joint Using a Retrograde Intramedullary Nail: A Retrospective Cross-sectional Study.

Severe septic destruction of the ankle joint poses a therapeutic challenge but lacks a consensus optimal treatment. Tibiotalocalcaneal arthrodesis (TTCA) is considered as a valuable salvage procedure, but the literature remains scarce. Conventional treatment approaches, including 2-stage procedures, have been associated with prolonged recovery times and varying success rates. Many authors prefer classical external fixation in these scenarios, citing concerns that internal implants might pose a risk for recurrent infection. To date, no study has investigated the outcomes of 1-stage surgery using a retrograde intramedullary (IM) nail. The main purpose was to assess the rate of recurrent infection at 2 years following 1-stage TTCA using a retrograde IM nail in severe septic destruction of the ankle joint. Fusion rates and functional outcomes were evaluated as secondary purposes. The clinical and radiologic data of patients who underwent 1-stage TTCA with retrograde IM nail following severe septic destruction of the ankle joint with a minimal follow-up of 2 years were retrospectively analyzed. Reinfection rate, fusion rate, functional outcomes, and complications were evaluated. A total of 25 patients were included with a mean follow-up of 42 months (24-92 months). The mean age was 55 ± 18 years old. At the last follow-up, reinfection occurred in 6 patients (24%) and fusion was obtained in 19 patients (83%). Eight patients (32%) required revision surgery. The mean postoperative modified American Orthopaedic Foot & Ankle Society (AOFAS) score, 12-Item Short Form Health Survey physical and mental component summary scores were respectively 53 ± 19.5, 35.5 ± 11.4, and 46.7 ± 13.5 points. One-stage TTCA with retrograde IM nail appears to be an acceptable alternative in severe septic destruction of the ankle joint, with a high eradication rate of infection and ankle fusion.

Functional Outcome of Extra-Articular Distal Tibia Fracture Treated with Tibia Interlocking Nail: A Case Series

Background: Intramedullary interlocking nailing has emerged as one of the suitable management options for distal tibia fractures as it allows mechanical compression on weight-bearing, which stimulates bone healing. We studied 40 cases of extra-articular distal tibia fracture treated by intramedullary nailing. Methods: We retrospectively studied 40 patients of both sexes above the age of 18 years with closed fractures and grade 1, 2, and 3A compound fractures treated at SVP Hospital, Ahmedabad, India. Clinically, the fracture was considered to be united when the patient was completely pain-free. Patients were followed up at monthly intervals till union. At each follow-up, patients were assessed both clinically and radiographically, and details were recorded based on proforma. Results: The evaluation of the result was done using American Orthopedic Foot and Ankle Society (AOFAS) criteria. Thirty-three patients had excellent functional results, five had good functional results, and Two had fair functional results. In this study, 38 (95%) patients had radiological union within 24 weeks. Two patients had union after 28 weeks. Conclusion: Intramedullary nailing is a minimally invasive procedure that preserves the soft tissue and the fracture hematoma. It maintains the length, alignment, and rotation and allows micromotion at the fracture site on weight-bearing, which stimulates callus formation. It has a good functional outcome with gratifying results when used in extra-articular distal tibia fractures.

Downregulation of Krüppel-like factor 15 expression delays endochondral bone ossification during fracture healing

ObjectiveThe role of Krüppel-like zinc finger transcription factor 15 (KLF15) in endochondral ossification during fracture healing remains unexplored. In this study, we aimed to elucidate the impact of KLF15 in a mouse model of tibial transverse fracture. MethodsWe created tamoxifen-inducible, cartilage-specific KLF15 knockout mice (KLF15 KO). KLF15 fl/fl Col2-CreERT mice from the same litters as the KLF15 KO mice, but not treated with 4-hydroxytamoxifen, were used as controls (CT). At 10 weeks, male KLF15 KO and CT mice underwent tibial fracture followed by intramedullary nailing. Both groups were administered tamoxifen at days 0, 3, and 7 after surgery. The tibiae were harvested on post-surgery days 7, 10, and 14 for radiological assessment using micro-computed tomography. Histological staining (Safranin-O) and immunohistochemistry for KLF15, SOX9, Indian hedgehog (IHH), RUNX2, and Osterix were performed. Additionally, cartilage from mouse fetus was cultured for qRT-PCR and western blot analyses of KLF15, SOX9, IHH, Col2, RUNX2, Osterix, TGF-β, SMAD3, and phosphor-SMAD3. ResultsThe radiological assessment revealed that immature callus formation was delayed in KLF15 KO, compared with that in CT, peaking on day 14 compared with that on day 10 in CT. KLF15 KO mice exhibited delayed fracture healing and reduced Safranin-O staining at days 7 and 10 post-surgery. The ratio of cells positive for KLF15 and SOX9 was significantly lower in KLF15 KO than in CT, whereas the ratios for IHH, RUNX2, and Osterix showed no significant difference. RT-PCR revealed reduced expression of KLF15, SOX9, and COL2, with no significant changes in IHH, Osterix, RUNX2, TGF-β, and SMAD3. Western blot analysis indicated decreased SMAD3 phosphorylation in KLF15 KO mice. ConclusionKLF15 regulates SOX9 via the TGF-β-SMAD3-SOX9 pathway, independent of IHH, in endochondral ossification. The KLF15 deficiency decreases SOX9 expression through reduced SMAD3 phosphorylation, subsequently delaying fracture healing.

Comparative Efficacy of Interlocking Intramedullary Nails and Percutaneous Plate Implantation in the Treatment of Femoral Shaft Fractures: A Meta-Analysis.

Interlocking intramedullary nailing and percutaneous plate implantation are commonly used techniques in the treatment of femoral shaft fractures. This study aimed to determine the most appropriate and effective treatment strategy between interlocking intramedullary nails and percutaneous plate implantation by analyzing and summarizing the available evidence. Relevant articles published from the date of database construction in PubMed, Embase, Web of Science, and Cochrane to 2024 were searched and downloaded according to PRISMA 2020. These studies were screened following pre-established inclusion criteria, and the data were extracted. Methodological quality assessment for retrospective studies was performed using the Newcastle-Ottawa Scale, whereas Review Manager Software was used for methodological quality assessment of randomized controlled trials (RCTs) and statistical analysis. Only 13 studies containing 1061 patients were included in the meta-analysis. Femoral shaft fractures treated with interlocking intramedullary nailing had shorter operative and fluoroscopic time and less estimated blood loss. Pediatric patients treated with interlocking intramedullary nails had less estimated blood loss and shorter healing time. Interlocking intramedullary nailing group in the retrospective study was associated with shorter operative time and less blood loss, whereas, in the randomized controlled trial (RCT) study, it was associated with less blood loss and shorter healing time. Interlocking intramedullary nailing is more advantageous in treating femoral shaft fractures and is a more appropriate option for treating femoral shaft fractures in pediatric patients. PROSPERO: CRD42024564563.

Comparison of treatment results of femoral shaft fracture with two methods of intramedullary nail (IMN) and plate

BackgroundFracture of the femur is one of the most common fractures that, if not stabilized and treated properly, may lead to severe disability, impairment of the individual’s efficiency, and numerous complications. This study aimed to evaluate the treatment results of femoral shaft fracture with two methods intramedullary nail (IMN) and Plate.Materials and methodsIn this cross-sectional study, 60 patients with femoral bone fractures were admitted to Imam Khomeini Hospital in Jiroft in 2020 and were treated for at least one year after discharge. They were divided into two treatment groups - Plate fracture fixation (n = 30) and IMN fracture fixation (n = 30). Data were collected using a researcher-made checklist including patient demographics and treatment outcomes. The collected data were analyzed using SPSS-v 26 statistical software and descriptive and inferential statistical tests at a significance level of p < 0.05.ResultsPatients in the Plate treatment group were generally older (50–60 years) compared to the IMN treatment group (30–40 years), and there were more men than women in both groups. Only 10% of patients in each group developed superficial infections after surgery. There were more cases of deep infections in the Plate group, but it was not statistically significant. The IMN group had fewer cases of malignancy and claudication compared to the Plate group. Patients in the IMN group also returned to functional activities faster than those in the Plate group, which was a statistically significant difference.ConclusionConsidering that deep infection, non-union, malunion, claudication, and ability to return to functional activities in the group using nails treated was less than the group treated with plates, the treatment method of femoral fracture using IMN is the preferred treatment method.

Lateral cortical notching for impaired healing of extra-articular proximal femur fractures (case report)

Introduction Dynamization of the nail can be used to improve osteoreparation during intramedullary interlocking nailing (IIN). The procedure can be difficult to perform in some sub- and intertrochanteric femoral fractures due to anatomical and functional features.The objective was to demonstrate a case of successful use of an original version of the lateral cortical notching (LCN) technique for dynamization of an intramedullary proximal nail in a patient with a nonunited subtrochanteric fracture.Material and methods The treatment was performed for a 66-year-old patient with a non-united intertrochanteric fracture of the right femur complicated by the breakage of an intramedullary nail. The LCN technique was successfully used to dynamize the IM nail.Results Radiological healing of the fracture and functional recovery of the patient were observed at a two-month follow-up. The absence of interfragmental compression in IIN could be caused by blocking of the sliding screw by the lateral cortical bone of the peripheral femur fragment. The complication could be prevented with LCN during primary osteosynthesis of the above fractures.Discussion Based on scientific publications and our clinical experience, we assumed that LCN can be indicated for failed healing of intertrochanteric AO/OTA 31A3.1–3 fractures, type 3 Boyd and Griffin trochanteric fractures and all types of subtrochanteric fractures as graded by Seinsheimer with a vector of interfragmental compression to be created along the femur axis during cephalomedullary osteosynthesis. The case report showed the mechanism of impaired consolidation in some intertrochanteric and subtrochanteric fractures of the femur.Conclusion The case report demonstrateed the successful use of the original version of the lateral cortical notching (LCN) technique for dynamization of an intramedullary proximal nail.

Single versus dual fixation of distal femur fractures: A retrospective cohort study at a level one trauma centre in New Zealand

Background The study compares single versus combination fixation of distal femur fractures. Method We retrospectively reviewed patients over 60 between January 2016 and December 2022. Union rate, ambulatory status and complication rate were primary outcomes. Secondary outcomes included quality of reduction, operative time and rate of blood transfusion. Results A total of 92 patients received single fixation, and 22 patients received combination fixation. There was no difference in rate or time of fracture union. Patients with dual fixation were allowed to weight bear on discharge significantly more than single fixation patients (50% vs. 18.9%, p = 0.003). Intramedullary nail fixation, as a single method or combined with lateral plating, was associated with earlier weight bearing. Immediate post-operative weight bearing significantly increased the likelihood of discharging to home or rehabilitation versus discharging to a transitional care facility ( p &lt; 0.00001). There was no difference in the rate of blood transfusion, complication or mortality. Medial translation of the distal articular block was significantly lower with dual fixation (1.2% vs. 3.4%, p = 0.021). Operation time was longer with combination fixation (183 min vs. 134 min p &lt; 0.001). Conclusion Combination fixation allows earlier weight bearing, at the cost of longer operation time.

Comparison of retrograde and antegrade tibial intramedullary nail in the treatment of extra-articular distal tibial fractures.

The aim of this study was to compare the effectiveness of retrograde and antegrade intramedullary tibial nails (RTN and ATN) in managing extra-articular distal tibial fractures, addressing current controversies in surgical approaches. A retrospective analysis included 56 patients treated between December 2019 and August 2022 with either RTN (n = 23) or ATN (n = 33). Data on baseline characteristics, operative specifics, fluoroscopy usage, hospitalization duration, fracture healing times, time to full weight-bearing, distal tibial alignment, American Orthopedic Foot and Ankle Society (AOFAS) scores at final follow-up, and complications were evaluated and compared. Baseline characteristics were generally comparable and no significant differences except for fracture line lengths (RTN: 6.1 ± 1.9cm vs. ATN: 7.8 ± 1.6cm) were observed. Follow-up ranged from 12 to 20 months. No significant differences were observed in operative duration, hospital stays, coronal angulation of the distal tibial joint surface, or AOFAS scores at final follow-up. Intraoperative fluoroscopy was more frequent in the ATN group (9.5 ± 1.5) compared to RTN (8.3 ± 1.1) (P = 0.001). RTN showed shorter healing times (9.6 ± 1.2 weeks) and quicker return to full weight-bearing (12.9 ± 1.3 weeks) than ATN (10.6 ± 1.2 weeks and 13.9 ± 1.7 weeks, respectively). RTN complications included one delayed union, one superficial infection, and two ankle pain, while ATN complications comprised one delayed union, one superficial infection, seven anterior knee pain, and one malalignment. Despite higher complication rates with ATN, the differences were not statistically significant. For the treatment of extra-articular distal tibial fractures, both RTN and ATN are effective approaches. RTN may offer benefits such as reduced fluoroscopy use, accelerated healing, and earlier return to full weight-bearing compared to ATN.

Angiogenesis-osteogenesis coupling and anti-osteoclastogenesis zoledronate intermixed calcium silicate metal-organic/inorganic hybrid coating on biodegradable zinc-based intramedullary nails for osteoporotic fracture healing

Osteoporotic (OP) fractures remain a tough clinical challenge owing to their impaired healing outcome, which requires novel biomaterials with osteogenicity for effective healing. Metallic zinc (Zn) is attracting increasing attention for biodegradable intramedullary nails (IMNs) for OP fracture healing thanks to their comprehensive mechanical properties, biosafety, and bioactivity. However, the multiple biofunctions required for OP fracture healing have not been fully met by Zn. Herein, a zoledronate (ZA)-mediated calcium-zinc silicate (Ca(Zn)Si) metal-organic/inorganic hybrid coating was fabricated on Zn-based IMN by coordination chemistry driven via interactions between ZA and Ca2+/Zn2+ as well as in-situ directional growth of Ca(Zn)Si phase. The ZA&Ca(Zn)Si hybrid coating exhibited a homogeneous micro/nanostructure with a granular morphology, which prevented premature fracture failure of IMN in rat femur by ameliorating corrosion mode and decreasing degradation rate of the Zn matrix. More importantly, this hybrid coating enabled sustained release of Zn2+/Ca2+/Si4+ and ZA in the long term, achieving a remarkable effect on vascularized bone regeneration. The coated IMN enhanced angiogenesis–osteogenesis coupling through autocrine and paracrine effects between endothelial cells and bone marrow mesenchymal stem cells. Osteoclastogenesis was repressed by Zn2+ and ZA. This approach offers a new strategy for surface-engineering of biodegradable metals for bone fracture healing.

Intramedullary nailing of coated and uncoated nails in infected tibial pseudarthrosis : Results of aretrospective examination of 56patients

In surgery for sepsis it is a well-established principle that no internal osteosynthetic material should be implanted in cases of chronic osteomyelitis. Therefore, the surgical treatment with intramedullary nails is so far used only rarely in cases of chronic osteomyelitis. This study analyzed whether the implantation of tibial intramedullary nails is an effective treatment for chronic osteomyelitis and how high is the rate of reinfection. A retrospective analysis of patients with an infected pseudarthrosis of the tibia in whom agentamycin-coated nail (ETN) or an uncoated tibial intramedullary nail (UCN) was implanted between December 2011 and December 2019 was carried out. The preoperative, perioperative and postoperative results were evaluated. During the study period 29 patients received a UCN and 27 patients received an ETN. Of the patients 95% (n = 53) had been previously unsuccessfully treated with external fixation. Postoperative complications occurred in 45% of the patients and more often in the ETN group (48% vs.41%). Reexacerbation of the infection occurred in 20 patients and more frequently in the UCN group (38% vs. 33%). The nonunion already showed abony consolidation at the time of the exacerbation in 10patients (50%). At the end of the follow-up aconsolidation was present in 48patients (86%), more frequently in the UCN group (90% vs.78%). Of the patients 50 (89%) reached full weight bearing without any differences between the groups. Despite arelatively high arate of postoperative complications the risk of reinfection was acceptable with good functional and radiological results. The main general advantages of nailing are without doubt the high primary stability, the implantation with preservation of the soft tissue and the improved wearing comfort for patients.

Cigarette Smoke Exposure Impairs Fracture Healing in a Rat Model: Preferential Impairment of Endochondral over Membranous Healing.

Cigarette smoking affects fracture repair, leading to delayed healing or nonunion. We sought to investigate if cigarette smoke differentially affects intramembranous and endochondral ossification in healing fractures, focusing on whether endochondral ossification is particularly impaired. This study utilized a bilateral femur fracture model in Sprague Dawley rats to examine the impact of cigarette smoke exposure on healing of femur fractures, treated with either a custom-locked intramedullary nail or compression plating to induce endochondral and membranous ossification, respectively. Animals were exposed to tobacco smoke 30 days before and after surgery, with evaluations including radiographs, histomorphometry, and microCT at 10 days, 1, 3, and 6-months post-operation, and biomechanical testing at 3, 6 months. Sixty-eight animals were randomized to control or exposure groups (two died perioperatively), and 89% of the femora achieved union when harvested at 3 and 6 months. Smoke exposure delayed cartilaginous callus formation and bone maturation in nailed fractures compared to plated fractures and controls in same animals. Plated fractures in exposed animals exhibited little cartilage callus and healed like control animals. At 3 months, plated fractures were stiffer and stronger than nailed fractures in both groups, but these differences vanished by 6 months. Plated fractures healed more rapidly and more completely than nailed fractures under both control and smoke-exposed conditions. Using compression plating instead of IM nailing for closed long bone fractures may lead to better outcomes in patients who smoke compared to current results with nailing.

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.

Sliding hip screw versus intramedullary nail for trochanteric hip fracture regarding death within 120 days and ability to return to independent living.

The primary aim of this study was to compare surgical methods (sliding hip screw (SHS) vs intramedullary nailing (IMN)) for trochanteric hip fracture in relation to death within 120 days after surgery and return to independent living. The secondary aim was to assess whether the associations between surgical method and death or ability to return to independent living varied depending on fracture subtype or other patient characteristics. A total of 27,530 individuals from the Swedish Hip Fracture Register RIKSHÖFT (SHR) aged ≥ 70 years, admitted to hospital between 1 January 2014 and 31 December 2019 with trochanteric hip fracture, were included. Within this cohort, 12,041 individuals lived independently at baseline, had follow-up information in the SHR, and were thus investigated for return to independent living. Death within 120 days after surgery was analyzed using Cox regression with SHS as reference and adjusted for age and fracture type. Return to independent living was analyzed using logistic regression adjusted for age and fracture type. Analyses were repeated after stratification by fracture type, age, and sex. Overall, 2,171 patients (18%) who were operated with SHS and 2,704 patients (18%) who were operated with IMN died within 120 days after surgery. Adjusted Cox regression revealed no difference in death within 120 days for the whole group (hazard ratio 0.97 (95% CI 0.91 to 1.03)), nor after stratification by fracture type. In total, 3,714 (66%) patients who were operated with SHS and 4,147 (64%) patients who were operated with IMN had returned to independent living at follow-up. There was no significant difference in return to independent living for the whole group (odds ratio 0.95 (95% CI 0.87 to 1.03)), nor after stratification by fracture type. No overall difference was observed in death within 120 days or return to independent living following surgery for trochanteric hip fracture, depending on surgical method (SHS vs IMN) in this recent Swedish cohort, but there was a suggested benefit for SHS in subgroups of patients.

Differentiated Approach to Surgical ­Treatment of Gunshot Diaphyseal Shin Fractures

Background. The roots of problems in the treatment of gunshot fractures to extremities lay in the high-energetic character of these traumas, the frequency of infectious complications, high rate of slow consolidations, and occurrence of pseudoarthroses and bone tissue lesions. Objective. The objective of the study was to improve the treatment results of patients with gunshot fractures of the shin bones based on the development of a differentiated approach to the treatment of such injuries. Material and Methods. The study is based on the results of examination and treatment of 128 patients with dominant combat shin traumas. The patients were divided into two groups. The first group (control group) included 68 patients who underwent treatment with an external fixation device (EFD). The second group (study group) included 60 patients who underwent the extrafocal osteosynthesis replaced by an internal, mostly intramedullary one. To assess the functional outcomes of treatment, we applied the LEFS (Lower Extremity Functional Scale) in the dynamics of the therapy, namely in 3, 6, 12, and 18 months after the injury. Results. Mean values in both groups during the first two to three weeks showed no statistically significant difference, and their average score according to the LEFS scale was 15.75 points. The most significant differences were observed in the period from 6 to 12 months after the injury, 39.4±2.4 (EFD) and 57.3±2.1 (intramedullary nailing). After 18 months, excellent results showed 20.7% of patients from the study group and 15.8% of the control group (61 – 80 LEFS scores). Good results had 43.2% and 33.1%, respectively (41 – 60 LEFS scores). 28.1% and 39.3%, respectively, showed satisfactory results (21 – 40 LEFS scores). Poor results showed 8.0% of patients of the study group and 11.8% of the control group (p&lt;0.05). Conclusions. The analysis of treatment outcomes of patients with gunshot diaphyseal shin fractures demonstrates that conversion, when used according to indications and following criteria to the replacement of the method of fixation, reduces the incidence of complications in both the early and late postoperative periods, fastens consolidation of gunshot diaphyseal shin fractures by 4.5±2.3 weeks, reduces the frequency of fracture consolidation disorders by 10.6%, and improves the functional results of the patients by 15.0%.

Epidemiology, Classification and Treatment of Femur and Tibia Fractures around Total Knee Arthroplasty (Literature Review)

Summary. Periprosthetic fractures around total knee arthroplasty (TKA) are difficult to treat due to complex fracture morphology, high proportions of injuries associated with osteopenia, and the variability of injury patterns. Periprosthetic fractures associated with TKA are defined as fractures around the knee joint (femur, tibia, or patella) occurring within 5 cm of the intramedullary stem of the prosthesis or 15 cm of the joint. The incidence is estimated to be between 0.3% and 2.5% after primary TKA and up to 28% after revision TKA. There are several surgical and nonsurgical risk factors associated with postoperative periprosthetic fractures. Distal femoral periprosthetic fractures following TKA are the most common and reported to occur in 0.2–1.8% of patients after primary TKA. Tibial periprosthetic fractures have a reported prevalence of 0.07–0.1% in primary and 0.36% in revision knee arthroplasties. Patella fractures are the second most common periprosthetic fractures following TKA, with prevalence ranging from 0.68% to 1.19%, and are usually associated with a resurfaced patella. Several classification systems of periprosthetic fractures around TKA have been published and some treatment recommendations have been provided. However, most systems are subject to criticism and use different classification systems for the tibia, patella, and the femur.A variety of treatment methods are available for periprosthetic fractures. Conservative treatment can include protected weight bearing, splinting, or traction. Surgical treatment commonly involves closed intramedullary nailing or open reduction and internal fixation by plates. In cases of significant bone loss, a revision TKA may be indicated. In general, treatment must be guided based on the stability of the implant and the remaining bone quality, as determined by the presence of osteolysis and the location of the fracture.

Impact of Surgical Timing on Fracture Healing in Tibial Shaft Injuries: A Comparative Review of Intramedullary Nailing Techniques

Impact of Surgical Timing on Fracture Healing in Tibial Shaft Injuries: A Comparative Review of Intramedullary Nailing Techniques