Nailing Of Tibial Shaft Fractures Research Articles

Tibial Malalignment is an Independent Predictor of Nonunion After Intramedullary Nailing of Tibial Shaft Fractures.

This study aimed to assess the relationship between postoperative alignment and nonunion in patients with tibial shaft fractures treated with intramedullary nailing. Design: Retrospective case-control study. Single academic trauma center. Adult patients with closed or open tibial shaft fractures (42A-C) treated with intramedullary nailing from 2007 to 2018. Case patients with nonunion were compared to control patients with radiographic evidence of healing in terms of the postoperative tibial alignment measured in the coronal and sagittal planes. Of the 192 included patients (median age, 38 years; 76% male), 51 patients had a nonunion, and 141 patients had united fractures and served as the control group. A strong association between postoperative tibial malalignment in one plane and nonunion (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.1 to 8.3; P = 0.03) was demonstrated. This association was even greater for malalignment in both coronal and sagittal planes (OR, 5.7; 95% CI, 2.1 to 16.1; P < 0.001) after controlling for confounders. After controlling for confounding factors, postoperative malalignment in the coronal or sagittal plane was associated with significantly increased odds of tibial shaft nonunion after intramedullary nailing. Therapeutic, Level III. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary nailing of tibial shaft fractures in the semi-extended position using suprapatellar approach: A case series in Hong Kong

Introduction The objective of this case series is to evaluate the clinical outcome of patients with tibial shaft fractures treated by suprapatellar nailing at a 2-year follow-up and to review available literature concerning this approach. Method and material This is a retrospective single-centre case series to evaluate patients' post-operative status at 2-year intervals. Fifteen (15) patients underwent intramedullary nailing with a supra-patella approach during the year 2019–2020 and consented to participate in this case series. Patients were regularly followed up in the outpatient clinic and evaluated in terms of range of movement, walking status and radiologically with RUST score and tibia alignment. Their functional outcome was assessed by a questionnaire including OKS, VAS, and Kujula scores. Results At post-op 2 years intervals, all patients had radiologically healed fractures as evidenced by RUST score and tibia alignment within five degrees in the coronal and sagittal plane, the functional outcome of the suprapatellar approach was satisfactory in the visual analogue scale and various knee scores. All patients achieved a full range of movement and could walk unaided. Discussion Technical tricks and tips for the suprapatellar approach are discussed. Literature review showed satisfactory outcomes for intramedullary nailing for tibial shaft fracture in different parts of the world. Compared with the infra-patellar approach, the suprapatellar approach is superior in fracture alignment but has no significant difference in terms of pain, disability and range of movement. Potential risk of suprapatellar approach is discussed including possible cartilage damage and intra-articular sepsis. Conclusion There is a good clinical outcome of the suprapatellar approach to tibial nail radiologically and functionally. Results are in line with the literature review, which also showed that compared with the infra-patellar approach, the suprapatellar approach is associated with better alignment and less knee pain but no significant difference in range of movement and disability.

383 Assessing Knee Pain Following Intramedullary Nailing for Tibial Shaft Fractures: Retrospective Analysis of Patient Outcomes at Single High Volume Major Trauma Centre

383 Assessing Knee Pain Following Intramedullary Nailing for Tibial Shaft Fractures: Retrospective Analysis of Patient Outcomes at Single High Volume Major Trauma Centre

Comparative Analysis of Infrapatellar and Suprapatellar Nailing Techniques for Tibial Shaft Fractures

Introduction: Tibial shaft fractures pose a significant challenge in orthopaedic practice, often necessitating surgical intervention for optimal recovery. The selection of the entry point for intramedullary nailing, particularly between the suprapatellar and infrapatellar approaches, remains a debated aspect in fracture management. While both approaches aim to restore stability and function, their nuances influence outcomes and patient experiences. This study aims to comprehensively compare the suprapatellar and infrapatellar approaches, analyzing surgical techniques, complications, and functional outcomes to inform clinical decision-making. Methodology: A retrospective comparative analysis was conducted on patients undergoing intramedullary nailing for tibial shaft fractures, comparing outcomes between the suprapatellar and infrapatellar approaches. Data collection included patient demographics, fracture characteristics, intraoperative details, and postoperative outcomes. Statistical analysis was performed using appropriate tests, with a significance level set at p &lt; 0.05. Result: Operative time was longer in the infrapatellar group (137.8 minutes) compared to the suprapatellar group (114.4 minutes). The mean radiation dose was higher in the infrapatellar group (74.3 cGY/cm2) and lower in the suprapatellar group (48.5 cGY/cm2). Postoperative outcomes showed a mean Lysholm score of 74 in the infrapatellar group and 90 in the suprapatellar group. one case of infection and one case of malunion were reported in the infrapatellar group, while the suprapatellar group had one infection case but no instances of non-union or malunion. Conclusion: This study provides valuable insights into the surgical and clinical outcomes of the suprapatellar and infrapatellar approaches for tibial shaft fractures. While both techniques offer viable options, the suprapatellar approach may offer advantages in terms of operative efficiency and functional recovery.

Rotational Malalignment After Intramedullary Nailing of Tibial Shaft Fractures Is Predictable.

Intramedullary nailing is the treatment of choice for most tibial shaft fractures (TSF). However, an iatrogenic pitfall may be rotational malalignment. The aim of this retrospective analysis was to determine predictors of rotational malalignment following intramedullary nailing of TSF. Retrospective study. Single level 1 trauma center. Patients who had a unilateral intramedullary nailing for TSF with a low-dose bilateral postoperative CT to assess rotational malalignment. Bivariable analysis followed by multivariable analysis was then undertaken to assess for any independent predictors, such as fracture type/sight, surgeon experience, and side of fracture, predictive of rotational malalignment. In total, 154 patients (71% male, median age 37 years) were included in this study. Thirty-nine percent of variability in postoperative rotational malalignment could be explained using a model including (increased) tibial torsion of the noninjured side (mean [38.9 degrees ± 9.02 degrees] considered normal tibial torsion), side of tibial fracture, and spiral-type tibial fracture (R2 = 0.39, P ≤ 0.001, F = 31.40). In this model, there was a negative linear association between degrees of torsion on the noninjured side and rotational malalignment (-0.45, P < 0.001)-as baseline torsion increased from mean by 1 degree, malrotation in the opposite direction of 0.54 degrees seen. Positive linear associations between right-sided TSF and rotational malalignment (8.59 P < 0.001) as well as spiral fractures and rotational malalignment (5.03, P < 0.01) were seen. This study demonstrates that baseline reduced (internal) tibial torsion of the noninjured limb, spiral fractures, and right-sided TSF are predictive of postoperative external rotational malalignment. Conversely, increased baseline (external) tibial torsion of the noninjured limb and left-sided TSF are predictive of postoperative internal rotational malalignment. Surgeons may use this regression model preoperatively to predict what sort of postoperative rotational difference their patient may be prone to. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Plating as a reduction aid prior to intramedullary nailing of tibia fractures: a systematic review and meta-analysis.

The purpose of this meta-analysis is to analyse the literature on plate-assisted reduction during intramedullary nailing of tibial shaft fractures and to compare the rates of infection and nonunion. The databases Medline, Embase, and Web of Science were searched from inception to February 2022 for literature comparing plate-assisted reduction during intramedullary nailing of extra-articular tibia fractures to standard, closed means of reduction. Data were extracted and pooled in a random effects meta-analysis for the primary outcomes of nonunion and infection risk. Five comparative studies were identified including 520 total patients, of which 151 underwent tibial nailing with the use of plate-assisted reduction with an average follow-up time of 17.9months. Approximately two-thirds of patients retained the plate used to assist reduction during intramedullary nailing (102 of 151). Pooled analysis of the infection rates found no significant difference with plate-assisted intramedullary nailing (Risk Ratio [RR] 0.90, 95% CI 0.49-1.65, p = 0.72), and for nonunion rates, there was also no significant difference with plate-assisted intramedullary nailing (Risk Ratio [RR] 0.80, 95% CI 0.40-1.60, p = 0.53). Plate-assisted reduction during intramedullary nailing of tibia shaft fractures was not associated with an increased risk for nonunion or infection, and can be safely applied as an adjunct for reduction in challenging fracture patterns, without the need for later removal. However, evidence is quite limited and further investigation into the use of provisional plating as a technique is needed as its use in intramedullary nailing continues to expand.

Outcome Following Intramedullary Nailing of Tibial Diaphyseal Fractures: Suprapatellar Nail Insertion Results in Superior Radiographic Parameters But No Difference in Mid-Term Function.

The primary aim of this study was to compare the radiographic parameters (nail insertion-point accuracy [NIPA] and fracture malalignment) of patients who had undergone tibial intramedullary nailing via the suprapatellar (SP) and infrapatellar (IP) approaches. The secondary aims were to compare clinical outcomes and patient-reported outcomes (PROs) between these approaches. All adult patients with an acute tibial diaphyseal fracture who underwent intramedullary nailing at a single level-I trauma center over a 4-year period (2017 to 2020) were retrospectively identified. The nailing approach (SP or IP) was at the treating surgeon's discretion. Intraoperative and immediate postoperative radiographs were reviewed to assess NIPA (mean distance from the optimal insertion point) and malalignment (≥5°). Medical records and radiographs were reviewed to evaluate the rates of malunion, nonunion, and other postoperative complications. The Oxford and Lysholm Knee Scores (OKS and LKS) and patient satisfaction (0 = completely dissatisfied, 100 = completely satisfied) were obtained via a postal survey at a minimum of 1 year postoperatively. The cohort consisted of 219 consecutive patients (mean age, 48 years [range, 16 to 90 years], 51% [112] male). There were 61 patients (27.9%) in the SP group and 158 (72.1%) in the IP group. The groups did not differ in baseline demographic or injury-related variables. SP nailing was associated with superior coronal NIPA (p < 0.001; 95% confidence interval [CI] for IP versus SP, 1.17 to 3.60 mm) and sagittal NIPA (p < 0.001; 95% CI, 0.23 to 0.97 mm) and with a reduced rate of malalignment (3% [2 of 61] versus 11% [18 of 158] for IP; p = 0.030). PROs were available for 118 of 211 patients (56%; 32 of 58 in the SP group and 86 of 153 in the IP group) at a mean of 3 years (range, 1.2 to 6.5 years). There was no difference between the SP and IP groups in mean OKS (36.5 versus 39.6; p = 0.246), LKS (71.2 versus 73.5; p = 0.696), or satisfaction scores (81.4 versus 79.9; p = 0.725). Compared with IP nailing, SP nailing of tibial shaft fractures was associated with superior NIPA and a reduced rate of intraoperative malalignment but not of malunion at healing. However, the superior NIPA may not be clinically important. Furthermore, there were no differences in PROs at mid-term follow-up. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Clinical validation of the ‘C-arm rotational view (CARV)’: study protocol of a prospective randomised controlled trial

IntroductionRotational malalignment occurs in up to 30% of cases after intramedullary nailing of tibial shaft fractures. The aim of this study is to assess the clinical feasibility of a newly...

Assessing the effectiveness of intramedullary nailing for tibial shaft fractures in a low-income setting: a prospective study in Yemen.

Tibial shaft fractures are common injuries that can be treated with various methods, including interlocked intramedullary nail (IMN). However, there is limited data on the clinical outcomes of IMN for tibial shaft fractures in Yemen. To evaluate the clinical outcomes of primary IMN for tibial shaft fractures in Yemen. This was a prospective study of 134 patients who underwent primary IMN for tibial shaft fractures et al.-Thawra Modern General Hospital in Sana'a, Yemen, between June 2016 and June 2020. The patients were between 18 and 70years old, and the fractures were classified according to the AO classification system. The fractures were treated with IMN using a standard technique. The patients were followed up for a minimum of 2years. The outcome measures included union time, complications, and functional scores. The mean union time was 17weeks. The overall complication rate was 18.7%. The most common complications were infection (8.2%), delayed union (6.7%), and nonunion (3.7%). The mean functional scores at the final follow-up were 91.4 for the Knee Society Score and 90.2 for the American Orthopaedic Foot and Ankle Society Score. Primary IMN is an effective and reliable method for treating tibial shaft fractures in Yemen, with acceptable union time, complication rate, and functional outcomes.

FUNCTIONAL OUTCOME FOLLOWING DIFFERENT SURGICAL APPROACHES FOR TIBIAL NAILING

Tibial shaft fractures require surgical stabilization preferably by intramedullary nailing. However, patients often report functional limitations even years after the injury. This study investigates the influence of the surgical approach (transpatellar vs. parapatellar) on gait performance and patient reported outcome six months after surgery.Twenty-two patients with tibial shaft fractures treated by intramedullary nailing through a transpatellar approach (TP: n=15, age 41±15, BMI 24±3) or a parapatellar approach (PP: n=7, age 34±15, BMI 23±2) and healthy, matched controls (n=22, age 39±13, BMI 24±2) were assessed by instrumented motion analysis six months after intramedullary nailing. Short musculoskeletal function assessment questionnaire (SMFA) as well as kinematic and kinetic gait data were collected during level walking. Comparisons among approach methods and control group were performed by analysis of variance and Mann-Whitney test.Six months after surgery, knee kinetics in both groups differed significantly compared to controls (p &lt;.04). The approach method affected gait speed (TP: p = .002; PP: p = .08) and knee kinematics in the early stance phase (TP: p = .011; PP: p = .082), with the parapatellar approach showing a more favorable outcome. However, the difference between patient groups was not significant for any of the assessed gait parameters (p &gt; .2). Also, no differences could be found in the bother index (BI) or function index (FI) of SMFA between surgical approach methods (BI: TP: Mdn = 7.2, PP: Mdn = 9.4; FI: TP: Mdn = 10.3, PP: Mdn = 9.2, p &gt; .7).Our study demonstrates, that six months after surgery for tibial shaft fractures functional limitations remain. These limitations appear not to be different for either a trans- or a parapatellar approach for the insertion of the intramedullary nail. The findings of this study are limited by the relatively short follow up time period and small number of patients. Future studies should investigate the source of the functional limitation after intramedullary nailing of tibial shaft fractures.

Effect of fracture level on the residual fracture gap during tibial intramedullary nailing for tibial shaft fractures.

The development of fracture gap during intramedullary nailing in tibial fractures is associated with poor fracture fragment contact and increased time to union and complications. This study aimed to evaluate the effect of the fracture level in the development of the fracture gap and the effect of the fracture gap on pain, radiologic and functional outcomes, and complication rate. A total of 45 patients who underwent reamed intramedullary nailing due to closed transverse or short oblique tibial shaft fractures were divided into the proximal fracture group and the distal fracture group. The correlations between the visual analog scale (VAS) score, modified radiograph union score for tibias (RUST), and postoperative 1-year lower extremity functional scale scores, residual fracture gap, and time to union were evaluated. The mean fracture gap amounts in the immediate postoperative anteroposterior and lateral radiographs were 5.6±1.7 and 6.0±1.7mm in proximal fractures and 0.3±2.4mm and 0.4±2.3mm in distal fractures, respectively (p<0.001 and p<0.001, respectively). The mean time to union was 21.9±2.9 weeks in the proximal fracture group and 16.7±2.4 weeks in the distal fracture group (p<0.000). The residual fracture gap amount significantly correlated with the level of fracture (r=0.811, p<0.001). Tibial shaft fractures proximal to the isthmus level tend to develop significantly larger fracture gaps than distal fractures. It is associated with increased time to union and radiographic union scores as well as slightly higher complication and reoperation rates.

A Novel Technique for Obtaining Neutral Entrance Angle During Suprapatellar Nailing of Tibial Shaft Fractures

A Novel Technique for Obtaining Neutral Entrance Angle During Suprapatellar Nailing of Tibial Shaft Fractures

Butterfly fragments in diaphyseal tibial fractures heal unpredictably: Should we be adopting other strategies for these high risk fractures?

The natural history of diaphyseal tibial butterfly fragments is poorly documented. Numerous studies have analyzed risk factors for nonunions in the tibial shaft with known factors including Gustilo classification, ASA class, and cortical contact. However, the healing potential and ideal management of nonsegmental butterfly fragments in this setting remains unknown.The aim of this study was to determine the nonunion rate of diaphyseal tibial fractures with a butterfly fragment. A performed a retrospective review of patients at a single academic Level 1 Trauma Center from 2000-2020 who underwent intramedullary nailing of tibial shaft fractures. Those with non-segmental butterfly fragments (OTA/AO: 42-B) and minimum 12 month follow up were included. Morphologic measurements of butterfly fragments were performed to measure location, size, and displacement, and mRust scores at final follow up were calculated. Outcome measures were surgery to promote union, and mRust scores. A total of 99 patients were included with 21 patients requiring revision surgery to promote union. Thirty six patients had open fractures and 77% of patients were male with a mean age of 34 (range: 12-80). Average follow up was 19 months (3 months - 12 years). The most common location of the butterfly fragment was the anterior cortex (42%), with a mean length of 7.8cm (SD: 3.3) and width of 1.8cm (SD: 0.5cm). At final follow-up 37% of fractures had persistent lucency without callus at the site of the butterfly while only 31% of fractures had remodeled cortex. Average time to complete healing was 13.3 months. Open fractures with butterfly fragments were more likely to go on to nonunion than closed (44% vs 9.2%, p=<0.001). The length of the butterfly fragment was not different between the union and nonunion groups (7.7 vs 7.5, P=0.42). Open tibial shaft fractures with a butterfly fragment have a high risk of nonunion. Further research may seek to determine if adjunct treatment of butterfly fragments (ie inter-fragmentary compression) in the acute setting could improve healing rates.

If Socioeconomic Stress Is a Relevant Factor in Fracture-Healing Outcomes, Should It Also Merit Intervention?: Commentary on an article by Zachery Hong, MPHS, et al.: "The Effect of Social Deprivation on Fracture-Healing and Patient-Reported Outcomes Following Intramedullary Nailing of Tibial Shaft Fractures".

If Socioeconomic Stress Is a Relevant Factor in Fracture-Healing Outcomes, Should It Also Merit Intervention?: Commentary on an article by Zachery Hong, MPHS, et al.: "The Effect of Social Deprivation on Fracture-Healing and Patient-Reported Outcomes Following Intramedullary Nailing of Tibial Shaft Fractures".

Preoperative and Intraoperative Considerations Using Intramedullary Nails for the Treatment of Tibial Shaft Fractures Below Total Knee Arthroplasty.

Periprosthetic tibial shaft fractures below total knee arthroplasty (TKA) are relatively rare, with an incidence of approximately 1%. However, as the rates of arthroplasty increase, orthopaedic surgeons are likely to see a corresponding increase in these types of fractures. Native tibial shaft fractures are routinely treated with either nails or plates, and the success of intramedullary nailing of tibial shaft fractures has been well described in the literature. In this article, we seek to describe a case series of tibial shaft fractures in patients with ipsilateral TKA treated with infrapatellar intramedullary nailing. We will focus on preoperative considerations including templating and measurement of the anterior cortical implant distance on the lateral radiograph to ensure space for safe nail passage. We will also discuss intraoperative technical tricks, including Kirschner wire insertion for sounding the start point, utilization of the curved awl, use of hand reamers, and rotation of the nail to bypass the implant. Using meticulous preoperative planning and technical intraoperative tricks, patients with tibial shaft fractures below TKA may be successfully treated with intramedullary nailing.

Tibial Intramedullary Nailing by Suprapatellar Approach: Is It Quicker and Safer?

Background With the increasingly accepted method of suprapatellar tibial nailing for tibial shaft fractures, we aimed to compare intraoperative and postoperative outcomes of infrapatellar (IP) vs suprapatellar (SP) tibial nails. Methods This is a retrospective cohort analysis of 34 SP tibial nails over three years vs 24 IP tibial nails over a similar time frame. We comparedtotal radiation dose (TRD), patient positioning time (PPT), fracture healingand follow up time. Knee pain in the SP group was evaluatedutilising the Hospital for Special Surgery (HSS) Knee Injury and Osteoarthritis Outcome Score (KOOS). Results Fifty-eight patients with a mean age of 43 years were included. Mean intraoperative radiation dose for SP nails was 61.78 cGy (range: 11.60-156.01 cGy) vs 121.09 cGy (range: 58.01-18.03 cGy) for IP nails (p < 0.05). Mean PPT for SP nails was 10 minutes vs 18 minutes for IP nails (p < 0.05). All fractures united in the SP group vs one non-union in the IP group. Mean follow up was 5.5 months vs 11 months in the IP and SP groups, respectively. Mean KOOS was 7 (range: 0-22) at six months for the SP group. Conclusion The semi-extended position (SP group) leads to reduced TRD because of ease of imaging. Patients showed improved outcomeswith shorter follow up and fracture union in all patients (SP group). The KOOS revealed that SP nail patients had minimal pain and good knee function. This study establishes a management and patient-reported outcome measures (PROMs) baseline for ongoing evaluation of SP nails.

The Effect of Social Deprivation on Fracture-Healing and Patient-Reported Outcomes Following Intramedullary Nailing of Tibial Shaft Fractures.

Social deprivation is a state marked by limited access to resources due to poverty, discrimination, or other marginalizing factors. We investigated the links between social deprivation and orthopaedic trauma, including patient-reported outcomes, radiographic healing, and complication rates following intramedullary nailing of tibial shaft fractures. We retrospectively reviewed 229 patients who underwent intramedullary nailing of tibial shaft fractures at our Level-I trauma center. The Area Deprivation Index (ADI), a validated proxy for social deprivation, was used to group patients into the most deprived tercile (MDT), the intermediate deprived tercile (IDT), and the least deprived tercile (LDT) for outcome comparison. The Patient-Reported Outcomes Measurement Information System (PROMIS) was used to measure the domains of Physical Function (PF), Pain Interference (PI), Anxiety, and Depression, and radiographic healing was assessed with the Radiographic Union Scale in Tibial fractures (RUST) system. On univariate analyses, patients from the MDT reported worse PF, PI, Anxiety, and Depression scores than those from the LDT within the first year of postoperative follow-up. On multivariable regression analysis, PROMIS score outcomes were influenced by age, race, and smoking status, but not by social deprivation tercile. Furthermore, residing in the MDT was associated with a 31% increase in time to radiographic union compared with the LDT (β = 0.27; p = 0.01). Following intramedullary nailing of tibial shaft fractures, social deprivation is associated with slower fracture-healing and potentially influences short-term PROMIS scores. These results warrant further investigation in additional patient populations with orthopaedic trauma and highlight the importance of developing interventions to reduce inequities faced by patients from low-resource settings. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Functional and Radiological Outcomes with Intramedullary Interlocking Nailing of Tibial Shaft Fracture

Introduction: Tibia is the most common long bone involved in fracture during Road Traffic Accident (RTA) because of its subcutaneous location. Intramedullary nail fixation remains the treatment of choice for unstable and displaced tibial shaft fractures in the adult. The goals of surgical treatment are to achieve osseous union and to restore length, alignment, and rotation of the fractured tibia. Intramedullary nailing carries the advantage of minimal surgical dissection with appropriate preservation of blood supply to the fracture site. Materials and Methods: This is a prospective observational study conducted in the Department of Orthopedics, National Medical College and Teaching Hospital,Birgunj, Parsa, Nepal for the 1 year duration. Patients included in this study were above 16 years with Tibia shaft fracture with or without fibula fracture which includes Type I,II and IIIA of Gustilo-Anderson fracture. Patients with tibia shaft fracture were treated surgically by using intramedullary interlocking nail then follow up done in OPD at regular intervals during which radiographs was taken in appropriate views and diagnosis is established by functional and radiological means. Result: Out of 53 patients, 45 patients with Tibia shaft fracture are treated by closed intramedullary interlocking nailing in the National Medical College, Birgunj. Eight patients are lost during follow-up. In our study tibia shaft Fracture was more common in male (77.8%) than female which mostly involved 18-30 years of age group (62.2%) and most common cause was Road Traffic Accident (82.2%). Thirty cases (66.7%) had excellent and 10 cases (22.2%) had good healing and complication were seen in eight patients (17.7%). Conclusion: Closed interlocking tibia nailing allows earlier fracture union with less morbidity. Because of the high union rate and low infection rate, we consider closed interlocking nailing as the best mode of treatment for diaphyseal tibial fractures.

A major trauma centre experience with gentamicin-coated tibial intramedullary nails (ETN PROtect™) in acute primary open fracture fixation and complex revision surgery.

Fracture-related infections (FRI) following intramedullary nailing for tibial shaft fractures remain challenging to treat with associated high patient morbidity and health care costs. Recently, antibiotic-coated nails have been introduced as a strategy to reduce implant related infection rates in high-risk patients. We present the largest single-centre case series on ETN PROtect® outcomes reporting on fracture union, infection rates and treatment complications. Fifty-six adult patients underwent surgery with ETN PROtect® between 01/09/17 and 31/12/20. Indications consisted of acute open fractures and complex revision cases (previous FRI, non-union surgery and re-fracture) with a mean of three prior surgical interventions. We report on patient demographics, union rates and deep infection. Minimum follow-up was one year. One (1.8%) patient developed a deep surgical infection and associated non-union requiring further surgery. In addition, we identified three cases (5.4%) of aseptic non-union following facture treatment with ETN PROtect®. Of the five patients who underwent staged complex revision surgery for established FRI with ETN PROtect®, all had treatment failure with ongoing symptoms of deep infection requiring implant removal and further treatment. Use of the ETN PROtect® nail in high-risk patients (open fractures and those initially treated with external fixation) and in those patients with aseptic non-unions, demonstrates promising outcomes in the prevention of implant-related infection. In our limited series we have failed to observe any benefit over uncoated nails, when used in treating cases of previously established FRI/osteomyelitis and would therefore advise caution in their use, especially in view of the high cost.

Suprapatellar intramedullary nailing of tibial shaft fractures in pregnancy. A report of two cases

BackgroundTreatment of closed tibial shaft fractures in the 3rd trimester of pregnancy is controversial. Since there are few case reports published in literature, there is no consensus on the appropriate management of these fractures. This case report proposes intramedullary nailing throught the suprapatellar approach for the treatment of tibial shaft fracture in pregnant women, never described before in literature.Case presentationWe report 2 cases of a tibial diaphyseal fracture treated by intramedullary nailing in women at the 3rd trimester of pregnancy.ConclusionSurgical treatment of tibial shaft fracture of pregnant women in the 3rd trimester of pregnancy with intramedullary nailing seems to be safe. The use of the specific suprapatellar approach helps in the intra-operative management of the pregnant patients.