Union Rate Research Articles

LONG-TERM FOLLOW-UP, REOPERATIONS, AND PATIENT-REPORTED OUTCOMES FOLLOWING REVISION SURGERY FOR FAILED TOTAL ANKLE ARTHROPLASTIES

IntroductionPrimary ankle arthroplasty (TAR) is increasingly used to treat end-stage ankle arthritis. Reported revision rates of TAR vary from 8.5% to 11.1% at 9 years. Revision surgery remains technically challenging with options ranging from simple joint debridement to tibio-talar-calcaneal fusion. The efficacy of these procedures remains unclear and there is no consensus on optimal revision options.MethodsA retrospective cohort study was performed of all patients undergoing surgery for a failed primary TAR at the Nuffield Orthopaedic Centre (2004–2021). TAR failure was determined by clinical assessment, serial radiographs and CT scans. Primary outcome measures included type and time of index surgery post TAR. Secondary outcomes included frequency of re-operations, post-operative complications, patient reported outcomes and union rate (for revision arthrodesis procedures).Results70 failed TARs in 69 patients (35M:34F, mean 65.7 years, s.d.=11.6) underwent re-operation a mean of 6.24 years (range 1–30) post primary. In total, 107 operations were performed including revision fusion (n=50), revision arthroplasty (n=14), bearing exchange (n=9) and joint clearance (n=9). The overall revision fusion union rate was 73.5% over a mean of 12.5 months (s.d.=7.6). 16/23 (69.6%) Tibio-Talo-Calcaneal and 9/12 (75%) ankle fusions (previous subtalar/triple fusion) using a hindfoot nail united over a mean 11.4 months (s.d.=6.0) and 15 months (s.d.=9.48) respectively. Only 64% of ankle fusions using screws alone united (mean=10.6 months, s.d.=8.14). The average post-operative MOXFQ score was 28.3 (s.d.=19.3). 73% said the operation improved their function and would recommend it to a friend/family member.ConclusionDespite low post-operative MOXFQ scores, over 70% of patients were satisfied with re-operation for a failed TAR. Over 26% of all TAR revision fusions fail to unite with the highest non-union rates observed post ankle arthrodesis with screws alone (36.4%).

Nitinol Staple Use in Primary Arthrodesis of Lisfranc Fracture-Dislocations.

Primary arthrodesis of Lisfranc fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion. Nitinol staple use has recently proliferated in midfoot arthrodesis. The purpose of this study is to examine the union rate of primary arthrodesis of acute Lisfranc fracture-dislocations treated with nitinol staples compared with traditional plate-and-screw fixation. The secondary objective is to assess the difference in operative times and reoperation rates. Midfoot fracture-dislocations treated with primary arthrodesis by 7 foot and ankle orthopaedic surgeons were reviewed. Of 160 eligible patients, 121 patients (305 joints) met the required 4-month minimum radiographic follow-up. Radiographic outcomes were analyzed at the individual joint level. Each joint was classified as either staples alone (45 patients, 154 joints), staples plus plates and screws (hybrid) (45 patients, 40 joints), or plates and screws alone (31 patients, 111 joints). The primary outcome was arthrodesis union at each joint fused. Nonunion was more common (9.0%, 10/111) among joints fixed with plate and screws than with hybrid (2.5%, 1/40) or staples only (1.3%, 2/154) (P = .0085). Multivariable regression demonstrated that autograft use was independent associated with union (P = .0035) and plate-and-screw only fixation was an independent risk factor for nonunion (P = .0407). Median operating room and tourniquet times were shorter for hybrid (92 and 83 minutes) and staple only (67 and 63 minutes) constructs compared to plate-and-screw only fixation (105 and 95 minutes) (P ≤ .0001 and .0003). There was no difference in reoperation rates among patients with different fixation types. We found that use of nitinol compression staple and bone autograft in primary arthrodesis of Lisfranc and midfoot fracture-dislocations was associated with both improved union rates and shorter tourniquet and operative times compared to traditional plate-and-screw fixation techniques. Level III, therapeutic.

FUNCTIONAL OUTCOME OF GIANT CELL TUMOR OF DISTAL RADIUS AFTER EN-BLOC RESECTION AND NON-VASCULARIZED FIBULAR BONE GRAFTING

Introduction: Giant cell Tumors (GCT) are relatively common lesions that are most often encountered in middle aged women [Salunke AA, Shah J, Warikoo V, Chakraborty A, Pokharkar H, Chen Y, Pruthi M, Pandit J. Giant cell tumor of distal radius treated with ulnar translocation and wrist arthrodesis. J Orthop Surg 2017 25(1): 2309499016684972, 2017, https://doi.org/10.1177/2309499016684972 ]. As 25% of these are usually locally aggressive, early diagnosis, and treatment are of paramount importance [Dorfman HD, Czerniak B. Bone Tumors. St. Louis, Mosby (1998)]. Due to the high incidence of local recurrence following simple curettage, it is no longer a preferred line of treatment. In recent times, extended curettage, wide resection or en-bloc resection with bone grafting have supplanted simple curettage [Şirin E, Akgülle AH, Topkar OM, Sofulu Ö, Baykan SE, Erol B. Mid-term results of intralesional extended curettage, cauterization, and polymethylmethacrylate cementation in the treatment of giant cell tumor of bone: A retrospective case series. Acta Orthop Traumatol Turc 54(5): 524–529, 2020, https://doi.org/10.5152/j.aott.2020.19082 ]. Case Scenario: A 22-year-old female patient presented to the OPD with a swelling in her right wrist which she noticed two years back. The swelling gradually increased to the size of a lemon at presentation and was initially painless but eventually became painful. The patient was evaluated based on clinical history, examination, and radiography. A clinical and radiological diagnosis of GCT of the distal radius was made. FNAC was done to confirm the same. Further, the lungs were screened for metastasis. She underwent en-bloc resection of the lesion followed by reconstruction with non-vascularized proximal fibular autograft secured with a DCP and [Formula: see text] -wires. The excised specimen was dispatched for Fig. 1. The swelling at presentation histopathological examination and confirmed to be a Giant Cell Tumor. Regular follow-up schedule was initiated at 2 weeks, 6 weeks, 3 months, 1 year, 36 weeks, and 2 years postoperatively. Her functional outcome was monitored by assessing the wrist range of movements and the Mayo wrist scores. Results: The patient’s Mayo wrist scores showed an increasing trend during follow-up, indicating improved functional outcomes. Recurrence was not noted during the follow-up period. Discussion: Tumor in the distal radius metaphyseoepiphyseal region is commonly associated with extracompartmental involvement, cortical invasion, and pathologic fracture [Yang YF, Wang JW, Huang P, Xu ZH. Distal radius reconstruction with vascularized proximal fibular autograft after en-bloc resection of recurrent giant cell tumor. BMC Musculoskelet Disord 17(1): 346, 2016. https://doi.org/10.1186/s12891-016-1211-8 ]. Hence, curettage is not an optimal method in the distal radius. Thus, wide excision is the optimal choice of treatment. However, this creates a defect at the distal end of the radius. The preferred options for the management of the defect comprise of osteoarticular allografts, vascularized grafts, non-vascularized bone grafts, and custom-made prostheses [Saini R, Bali K, Bachhal V, Mootha AK, Dhillon MS, Gill SS. En bloc excision and autogenous fibular reconstruction for aggressive giant cell tumor of distal radius: a report of 12 cases and review of literature. J Orthop Surg Res 6 : 14, 2011, https://doi.org/10.1186/1749-799X-6-14 ]. Vascularized bone grafts have been proposed to have a better union rate and lesser complication rate as compared to non-vascularized options. Thus, with our case report, we would like to highlight the effectiveness of the non-vascularized proximal fibular autograft in the reconstruction following en bloc excision of the distal radius. Conclusion: Hence, en-bloc resection and non-vascularized fibular bone grafting is a valuable method of treatment of GCTs of the distal radius. It is also associated with low recurrence rates and improved wrist function in the course of follow-up.

Risk factors of poor mid-term shoulder functional outcomes of osteosynthesis using antegrade intramedullary nailing for humeral shaft fractures: a retrospective study with a minimum 5-year follow-up

BackgroundOsteosynthesis using antegrade intramedullary nailing for humeral shaft fractures yields satisfactory bone union rates; however, it may adversely affect postoperative shoulder function. To date, factors affecting mid- or long-term shoulder functional outcomes following intramedullary nail fixation have not been clarified. In this study, we aimed to identify the risk factors for poor mid-term functional outcomes over 5 years postoperatively following antegrade intramedullary nail osteosynthesis for humeral shaft fractures.MethodsWe retrospectively identified 33 patients who underwent surgery using an antegrade intramedullary nail for acute traumatic humeral shaft fractures and were followed up for at least 5 years postoperatively. We divided the patients into clinical failure and no clinical failure groups using an age- and sex-adjusted Constant score of 55 at the final follow-up as the cutoff value. We compared preoperative, perioperative, and postoperative factors between the two groups.ResultsFive of the 33 patients had poor shoulder functional outcomes (adjusted Constant score < 55) at a mean follow-up of 7.5 years postoperatively. Proximal protrusion of the nail at the time of bone union (P = 0.004) and older age (P = 0.009) were significantly associated with clinical failure in the univariate analyses. Multivariate analysis showed that proximal protrusion of the nail (P = 0.031) was a risk factor for poor outcomes.ConclusionsThe findings of this study provide new information on predictive factors affecting mid-term outcomes following osteosynthesis using antegrade nails. Our results demonstrated that proximal protrusion of the nail was significantly associated with poor mid-term functional shoulder outcomes. Therefore, particularly in older adults, it is essential to place the proximal end of the intramedullary nail below the level of the articular cartilage.

The Effects of Longer Use of Teriparatide on Clinical and Radiographic Outcomes after Spinal Fusion in Geriatric Patients.

Background: Teriparatide is an anabolic agent for osteoporosis and is believed to improve the bone healing process. Previous studies showed that teriparatide could enhance not only fracture healing but also spine fusion. It has been reported that use of teriparatide could promote the spine fusion process and decrease mechanical complications. However, there was no consensus regarding optimal treatment duration. The purpose of this study was to compare surgical outcomes between short-duration and long-duration teriparatide treatment after lumbar fusion surgery in elderly patients. Materials and Methods: All consecutive patients older than 60 years who underwent 1-level lumbar fusion surgery for degenerative diseases between January 2015 and December 2019 were retrospectively reviewed. Based on the duration of teriparatide treatment (daily subcutaneous injection of 20 µg teriparatide), patients were subdivided into two groups: a short-duration (SD) group (<6 months) and a long-duration (LD) group (≥6 months). Mechanical complications, such as screw loosening, cage subsidence, and adjacent vertebral fractures, were investigated. Postoperative 1-year union rate was also evaluated on computed tomography. Clinical outcomes were recorded using visual analog scale (VAS) and Oswestry Disability Index (ODI). Between-group differences for these radiographic and clinical outcomes were analyzed. Results: Ninety-one patients were reviewed in this study, including sixty patients in the SD group and thirty-one patients in the LD group. Their mean age was 72.3 ± 6.2 years, and 79 patients were female. Mean T-score was -3.3 ± 0.8. Cage subsidence (6.7% vs. 3.2%), screw loosening (28.3% vs. 35.5%), and adjacent vertebral fracture (6.7% vs. 9.7%) were not significantly different between the SD and LD groups. Union rate at 1-year postoperative was 65.0% in the SD group and 87.1% in the LD group (p = 0.028). Both groups showed improvement in VAS and ODI after surgery. However, the differences of VAS from preoperative to 6 months and 1 year postoperative were significantly higher in the LD group. Conclusions: Longer teriparatide treatment after lumbar fusion surgery resulted in a higher union rate at 1-year postoperative than the shorter treatment. Also, it could be more beneficial for clinical outcomes.

Comparative Study of Union Rate in Closed Humerus Shaft Fracture After Operative Fixation with Anteromedial Versus Anterolateral Surface Plating Using the Anterolateral Approach: A Randomized Controlled Study

Purpose: Plate osteosynthesis is considered the gold standard for treating humeral shaft fractures, and orthopedic surgeons widely use the anterolateral approach with anterolateral surface placement. However, surgeons may have difficulties with the non-smooth surface and proximity to the radial nerve during their use. To address this challenge, we propose introducing the anterolateral approach with anteromedial surface placement. This study aimed to compare the outcomes between anteromedial and anterolateral surface plating using the anterolateral approach. Methods: This study included 74 patients who sustained a mid-shaft humerus fracture (AO 12) and underwent open reduction internal fixation between December 2020 and December 2022. Twelve patients were excluded based on the exclusion criteria. Among the remaining patients, 30 were randomized and allocated to surgery with anteromedial surface plating, while 32 patients were treated with anterolateral surface plating through an anterolateral approach. Postoperative clinical and radiographic results were recorded and analyzed. Results: The union rate, blood loss, operative time, and complications were not significantly different between the two groups. All the patients healed radiographically except for two in the anterolateral surface plating group, who required reoperation. Although anteroposterior alignment was significantly better in the anteromedial surface plating group, it was not clinically significant. Conclusions: Anteromedial plating demonstrated a commendable union rate, offered assured alignment, and presented itself as a secure option for addressing fractures of the humerus shaft.

The Role of Bone Grafting in Corrective Osteotomy of Distal Radius Malunions

Abstract Background It remains unclear whether bone grafting is required during corrective osteotomy of the distal radius. The goal of this systematic review is to determine the union, revision, and complication rates of bone grafting techniques associated with extra-articular corrective osteotomy for dorsally malunited distal radius fractures treated with volar plating. Questions Is bone grafting in distal radius corrective osteotomy associated with increased rates of bone union and reduced rates of revision surgery and complications? Methods A comprehensive search of the MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature databases was completed for studies reporting clinical outcomes of extra-articular corrective osteotomy for dorsally malunited distal radius fractures treated with volar plating. Results A total of 13 studies, with 14 intervention arms and 236 patients, were included. Bone grafting techniques consisted of autograft (6 studies, n = 93), synthetic bone grafts (2 studies, n = 38), allograft (1 study, n = 14), or no grafting (5 studies, n = 91). The overall union rate was 97%, and the mean time-to-union was 12.0 weeks. Larger corrections of dorsal tilt and ulnar variance were performed in the autograft and allograft groups. Complication and revision rates were highest in the synthetic group, 45 and 26.3% respectively. Conclusion Grafting in extra-articular corrective osteotomy for dorsally angulated distal radius malunions treated with volar plating is not associated with an improved union rate in the literature. However, larger corrections were achieved in both the autograft and allograft groups compared to the no-graft and synthetic groups, resulting in similar union rates. Synthetic bone grafting was associated with the highest complication and revision rates. Future comparative prospective trials and proper documentation of whether cortical contact was present or absent are required to assess whether bone grafting warrants consideration in more advanced deformities. Level of Evidence IV.

PREDICTORS OF METALWORK FAILURE AND NONUNION AFTER HINDFOOT CHARCOT RECONSTRUCTION

IntroductionSurgical reconstruction of deformed Charcot feet carries high risk of non-union, metalwork failure and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions.MethodsWe retrospectively analysed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between 2007 and 2019 in our unit. Patient demographics, co-morbidities, weightbearing status and post-operative complications were noted. Metalwork breakage, non-union, deformity recurrence, concurrent midfoot reconstruction and the measurements related to intramedullary nail were also recorded.ResultsThere were 70 patients with mean follow up of 50±26 months. Seventy-two percent were fully weightbearing at 1 year post-operatively. The overall union rate was 83%. Age, BMI, HbA1c and peripheral vascular disease did not affect union. The ratio of nail diameter and isthmus was greater in the united compared to the non-united group (0.90±0.06 and 0.86±0.09, respectively; p = 0.03). Supplemental compression devices were used for 33% of those in the united compared to 8% in the non-united group (p = 0.04). All patients in the non-union group did not have a miss-a-nail screw. Metalwork failure was seen in 13 patients(19%). There was a significantly greater distal screw metalwork failure in those with supplementary bridging of tibia to midfoot (23% vs. 3%; p = 0.001). An intact medial malleolus was found more frequently in those with intact metalwork (77% vs. 54%, respectively; p = 0.02) and those with union (76% vs. 50%; p = 0.02). Broken metalwork occurred more frequently in patients with non-unions (69% vs. 8%; p &lt; 0.001) and deformity recurrence (69% vs. 9%; p &lt; 0.001).ConclusionSatisfactory clinical and radiographic outcomes occur in over 80% of patients. Union after hindfoot reconstruction occurs more frequently with an isthmic fit of the intramedullary nail, supplementary compression and miss-a-nail screws. An intact medial malleolus is protective against non-union and metalwork failure. Broken metalwork is linked to deformity recurrence and non-union.

Wrist &amp; Hand

The June 2024 Wrist &amp; Hand Roundup360 looks at: One-year outcomes of the anatomical front and back reconstruction for scapholunate dissociation; Limited intercarpal fusion versus proximal row carpectomy in the treatment of SLAC or SNAC wrist: results after 3.5 years; Prognostic factors for clinical outcomes after arthroscopic treatment of traumatic central tears of the triangular fibrocartilage complex; The rate of nonunion in the MRI-detected occult scaphoid fracture: a multicentre cohort study; Does correction of carpal malalignment influence the union rate of scaphoid nonunion surgery?; Provision of a home-based video-assisted therapy programme in thumb carpometacarpal arthroplasty; Is replantation associated with better hand function after traumatic hand amputation than after revision amputation?; Diagnostic performance of artificial intelligence for detection of scaphoid and distal radius fractures: a systematic review.

Comparison of Ankle Fracture Fixation Using Intramedullary Fibular Nailing Versus Plate Fixation

Ankle fracture fixation using intramedullary fibular (IMF) nails has been shown to allow for earlier weightbearing, reduced wound complications, better union rates, and the absence of prominent hardware, compared to plates/screw (PS) constructs. The purpose of present retrospective cohort study was to compare outcomes of patients who underwent ankle fracture fixation using an IMF nail versus PS. Demographic, clinical, and radiographic data were recorded for patients who underwent ankle fracture fixation between May 2020 and May 2022, and who were at least 1 year postoperative. Toe-touch weightbearing was permitted immediately after surgery, protected weightbearing (PWB) at postoperative week 2, and weightbearing as tolerated in a brace at week 6. Radiographs were assessed preoperatively, and at 2, 6, 12, 24, and 48 weeks postoperative. Sixty-one ankle fractures (30 IMF, 31 PS) with a mean follow up of 14.7 and 18 (range, 12 to 23) months were included. Overall, the IMF nail cohort had less pain, faster time to union (11.4 vs 13.2 weeks), and less complications (23% vs 45%), reoperations (10% vs 16%), and surgical failures (9% vs 9.7%), compared to the PS cohort. The differences were not statistically significant. The PS cohort had a higher rate of symptomatic hardware irritation (p=<0.001). Tobacco use adversely effected direct osseous healing (p<0.001) and increased postoperative complications (p=0.050). The present study lends credence to the previously reported advantages of IMF nailing over PS fixation for ankle fractures. Ankle fracture fixation using a 4th generation, IMF nail is a viable alternative to traditional PS fixation.

The induced membrane technique for the management of infected segmental bone defects.

The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes. Between May 2012 and December 2020, 203 patients with infected segmental bone defects treated with the IMT were enrolled. The digital medical records of these patients were retrospectively analyzed. Factors associated with unfavourable outcomes were identified through logistic regression analysis. Among the 203 enrolled patients, infection recurred in 27 patients (13.3%) after bone grafting. The union rate was 75.9% (154 patients) after second-stage surgery without additional procedures, and final union was achieved in 173 patients (85.2%) after second-stage surgery with or without additional procedures. The mean healing time was 9.3 months (3 to 37). Multivariate logistic regression analysis of 203 patients showed that the number (≥ two) of debridements (first stage) was an independent risk factor for infection recurrence and nonunion. Larger defect sizes were associated with higher odds of nonunion. After excluding 27 patients with infection recurrence, multivariate analysis of the remaining 176 patients suggested that intramedullary nail plus plate internal fixation, smoking, and an allograft-to-autograft ratio exceeding 1:3 adversely affected healing time. The IMT is an effective method to achieve infection eradication and union in the management of infected segmental bone defects. Our study identified several risk factors associated with unfavourable outcomes. Some of these factors are modifiable, and the risk of adverse outcomes can be reduced by adopting targeted interventions or strategies. Surgeons can fully inform patients with non-modifiable risk factors preoperatively, and may even use other methods for bone defect reconstruction.

Long term follow up on treatment of hallux sesamoid fracture with temporary first metatarsal joint internal fixation

Fracture of the hallucial sesamoids is a pathology that causes difficulty for surgeons and patients. Because of the low incidence and the fact that up to 64–90 % heal with non-operative management, there is a lack of clear guidance in the literature for the surgical treatment of sesamoid fracture in cases of failure of non-operative management. Here long term follow up of an alternative method of surgical treatment of sesamoid fracture recalcitrant to nonoperative management is presented.32 individuals were treated with temporary surgical immobilisation of the 1st metatarsophalangeal joint using either crossed wires or two orthogonally placed two hole plates. The patients then underwent removal of the construct at 8 weeks post op after confirmation of healing on a CT scan. There was a 94 % union rate. Return to work was 61 days (15–90) return to sport 80 days (64–112) with no immediate complications and no recurrence. At last follow up mean 10 years (4–16) only 2 patients had gone on to asymptomatic non-union and one patient developed arthritis between the sesamoid and the metatarsal head. No patient has required further surgical intervention.This retrospective cohort of patients demonstrate that this method of treatment is a valuable option in the management of sesamoid fracture which does not alter the biomechanics of the foot and has none of the long term complications of sesamoidectomy or partial sesamoidectomy.

Three-corner arthrodesis for scapholunate and scaphoid nonunion advanced collapsed wrists: outcomes at long term follow-ups

ObjectivesThis study aimed to assess clinical, functional and radiological outcomes after three-corner arthrodesis in patients suffering from symptomatic scapholunate or scaphoid non-union advanced collapsed wrists. We hypothesised that three-corner arthrodesis provided satisfactory clinical and radiological results in the long term. Material and methodsThis was a retrospective study of 13 patients (14 wrists) who underwent a three-corner arthrodesis between March 2004 and January 2019 with a mean follow-up of 6,7 years. Clinical assessment consisted of wrist motion, grip strength, pain and functional scores (Quick-DASH, PRWE, MWS). All complications and surgical revisions were investigated. Radiographic assessment searched for union, evaluated carpal height and ulnar translation, lunate tilt and occurrence of radio-lunate arthritis. ResultsAt the last follow-up Quick-DASH and PRWE scores were 24,87(± 17.2) and 47.4 (± 26.9) respectively and were significantly improved. Wrist motion was 35°, 32°, 10° et 24° of flexion, extension, radial and ulnar deviation respectively. Union was obtained for 13 (92,9%) wrists. The mean radiolunate angle was 11° (-17°-34°). Three patients needed reintervention, which 2 consisted of total wrist arthrodesis due to persisting pain. Mild signs of radio-lunate arthritis were found in three patients. ConclusionThree-corner arthrodesis seemed to provide satisfactory long-term functional outcomes. The union rate was high and even patients with signs of radio-lunate arthritis still had improved outcomes at the last follow-up. It could be a part of surgical options in wrists with radio- and midcarpal arthritis, among other procedures.

Supracondylar ostectomy and shortening (S.O.S.) for distal humerus nonunions

Many distal humerus nonunions are associated with bone loss, and rigid internal fixation is difficult to obtain, especially for low transcondylar nonunions and those with severe intra-articular comminution. The purpose of this study was to analyze the results of a strategy to address this challenge utilizing internal fixation using the Supracondylar Ostectomy+Shortening (S.O.S.) procedure for distal humerus nonunions. The goals of this procedure are to (1) optimize bony contact and compression through re-shaping the nonunited fragments at the supracondylar level with selective humeral metaphyseal shortening, (2) maximize fixation using parallel-plating, and (3) provide biologic and structural augmentation with bone graft. Between 1995 and 2019, 28 distal humerus nonunions underwent internal fixation using the S.O.S. procedure at a single Institution. There were 14 males and 14 females with mean age of 47 (range 14-78) years at the time of the S.O.S procedure and an average of 1.7 prior surgeries. Medical records and radiographs were reviewed to determine rates of union, reoperations, complications, and Mayo Elbow Performance Scores (MEPS). Patients were also prospectively contacted to update their MEPS and gather additional information on complications and reoperations. Mean clinical exam follow-up was 17months, mean clinical contact follow-up was 19months, and mean radiographic follow-up was 32months. Four patients did not have adequate follow-up to determine union. Of the remaining 24 elbows, 22 achieved union. Two elbows developed collapse of the articular surface and were converted to a total elbow arthroplasty. There were complications in 10 elbows: contracture (5), superficial infection (2), ulnar neuropathy (1), deep infection (1), and hematoma (1). Twelve elbows underwent reoperation: 4 for contracture release, 3 for hardware removal, 2 for total elbow arthroplasty, 1 for bone grafting, 1 for hematoma evacuation, and 1 for ulnar nerve neurolysis. Compared to preoperative data, there was a significant improvement in postoperative flexion, extension and pronation (P<.01). The mean range of motion was 21° of extension, 119° of flexion, 79° of pronation, and 77° of supination. The mean MEPS was 80 points (range, 25-100 points) and 19 elbows (76%) rated as excellent or good. Stable fixation and high union rates are possible in distal humerus nonunions with bone loss using a technique that combines supracondylar humeral shortening, parallel plating, and bone grafting. Secondary procedures are commonly needed to restore function in this challenging patient population.

Displaced humeral shaft fractures: Assessment of fracture union and complications following dual plate fixation using an anterior approach

The humeral bone is subject to torsional forces. In case of displaced shaft fractures, internal fixation remains the standard of care. This retrospective two-center study assessed the fracture union rate and complications after dual 3.5 mm locking compression plate (LCP) fixation using an anterolateral approach. Over a 9-year period, 38 patients underwent surgery in two centers. They had a mean age of 53.7 years (15–97, ± standard deviation (SD) 26) and there were three open fracture cases (7.9 %). The dominant side was affected in 21 cases (55.3 %) and there were 11 polytrauma patients (29 %). Mean operative time was 78 min (40–124, ± 19.8 SD). Patients were treated with dual 3.5 mm LCP fixation (6 screws on either side of the fracture line, anterolateral approach without a tourniquet). The first two orthogonal views showing at least 3 cortical bridges out of 4 determined fracture healing, as assessed by two independent raters. Pre- and postoperative complications were tabulated. Clinical outcomes included range of motion (ROM) and return to activities, while functional outcomes were assessed with the Disability of the Arm Shoulder and Hand (DASH), the Constant score, the Subjective Shoulder Score (SSV) and the Mayo Elbow Performance Score (MEPS). Minimum follow-up was 1 year. Four patients were given a shoulder immobilizer to wear for 3 weeks; immediate mobilization was the standard of care for the other patients. Fracture union was achieved in all cases within a mean of 11.7 weeks (6–28 ± 7.1 SD) without any heterotopic ossification of the brachialis muscle. There were eight patients with preoperative radial nerve palsy and two cases of postoperative palsy. There was one surgical site infection (2.6 %). Return to work for active patients was possible in 87 % of cases within a mean of 23 weeks (6–72 ± 11 SD). The Constant score was 84.6 (35–100, ± 13.4 SD), the SSV score was 80.7 (60–100, ± 8.2 SD), the DASH score was 13.5 (0–38.3, ± 8.8 SD) and the MEPS score was 85 (55–100, ± 11.9 SD). Traditional fixation methods provide little control over torsional forces, leading to non-union rates between 3 % and 12 % and delayed union (12 to 20 weeks). The simplicity of the technique described here, and the short operative time, may help explain the low infection rate. Dual plate fixation makes it possible to use more screws and allows nerve exploration and decompression in case of preoperative nerve palsy. Dual plate fixation to treat humeral shaft fractures is a simple and reliable technique.

Nailing precision: a systematic review and meta-analysis of randomized controlled trials comparing piriformis and trochanteric entry points for femoral antegrade nailing.

Entry point selection, a crucial aspect of femoral antegrade nailing, can impact nail fit and consequently fracture reduction. In adults, the standard entry portals used are the piriformis fossa and the tip of the greater trochanter. Previous systematic reviews comparing the two techniques have not been limited to Randomized Controlled Trials (RCTs) and have not consistently included the same available RCTs. A systematic search of comparative studies regarding entry portal selection in femoral antegrade nailing was conducted on seven databases. Only Prospective RCTs comparing trochanteric and piriformis entry in the management of trochanteric or diaphyseal femur fractures were eligible for inclusion. Ultimately, only 6 RCTs were found eligible for inclusion. Five of the six included studies reported on operative time. The resulting mean difference (MD) illustrated a significant decrease in operative time by approximately 21.26min (95% CI - 28.60 to - 13.92, p < 0.001) using trochanteric entry. Fluoroscopy exposure was reported on by four studies, however, only two studies were included in the analysis due to different reporting methods. Trochanteric entry used significantly less fluoroscopy than piriformis entry (MD -50.33s, 95% CI - 84.441 to - 16.22, p = 0. 004). No significant difference in malalignment rates, delayed union rates, nonunion rates, pain scores, or complication rates was found. The significant differences found in operating time and fluoroscopy time align with those in other studies. While we were not able to pool the data on functional outcome scores, none of the included studies found a significant difference in scores by their last follow-up. Both approaches demonstrate comparable functional outcomes and safety profiles, indicating the choice of entry point should be at the discretion of the surgeon based on technique familiarity and fracture characteristics.

Activated allograft combined with induced membrane technique for the reconstruction of infected segmental bone defects

This study was desinged to evaluate the efficacy and safety of activated allograft combined with the induced membrane technique for reconstruction of infected segment bone defects of lower limbs. A retrospective analysis was conducted on 19 patients from May 2015 to February 2017. After debridements, the bone defects were filled with antibiotic bone cement to form the induced membrane. Autologous mesenchymal stem cells were seeded onto allografts to construct activated allograft, which was implanted into the induced membrane after infection was controlled. The clinical efficacy and complications were observed. 19 patients with 20 infected segment bone defect were evaluated. The average deficit size was 11.08 (4–17) cm in length. After a mean follow-up of 71.84 (61–82) months, bone union was achieved in 16 patients (17 sites), resulting in a final union rate of 84.21% (16/19 patients). The average bone union time was 10.18 (5–28) months. There were 2 patients with recurrence of infection, 3 patients with graft absorption, and 1 patient with malunion due to implant breakage. There were no graft-related complications. This study provides clinical significance for the treatment of patients with insufficient autologous bone.

Tratamiento quirúrgico de las fracturas bifocales ipsilaterales de tibia: un reto para el cirujano

IntroductionThe association of ipsilateral tibia fractures has a low incidence, being up to 3.2% of total tibia fractures. Currently there is no gold standard regarding the ideal surgical treatment.The objective of this study is to analyze the surgical treatment and the radiographic and functional results, as well as the associated complication rate of ipsilateral bifocal tibia fractures. Material and methodsRetrospective observational study in our hospital from 2010 to 2022 of 24 patients who underwent bifocal fracture of the ipsilateral tibia. Demographic and surgical data and complications during follow-up were included. ResultsThe 24 patients were classified into group 1 when they presented a fracture of the plateau and distal tibia (25%), group 2 with a fracture of the plateau and diaphysis (33%) and group 3 with a fracture of the diaphysis and distal tibia (42%). 3 patients underwent surgery with 1 implant and 21 patients with 2 implants. The average follow-up time in outpatient clinics was 2 and a half years. At one year, 22 patients (92%) had full weight bearing and 2 patients had partial weight bearing (8%) due to the sequelae of the fractures. The average time for consolidation of the diaphysis was 7.75±2 months, with no significant differences observed between group 2 and group 3 (p=0.06). The average time for consolidation of the metaphysis was 3.50±1.5 months, with no significant differences observed between group 1 and group 2 (p=0.065). 7 patients (30%) had complications during follow-up. ConclusionsBifocal tibia fractures can be treated using a combination of intramedullary nailing and plate osteosynthesis with good long-term results, obtaining an optimal union rate and low complications. In addition, it facilitates the reduction of the fracture, thus facilitating the patient's recovery and obtaining good long-term functional results.

Comparing Open and Arthroscopic Grafting for Scaphoid Nonunion: Is There Truly a Noticeable Difference?

Scaphoid nonunion remains a challenging injury with no clear consensus on treatment. Surgical options, such as bone grafting procedures, are available for the treatment of scaphoid nonunions. While open grafting provides direct visualization, it is theoretically believed to lead to several problems due to the complex ligamentous structure responsible for wrist stability and challenges in the vascular supply of the scaphoid. On the other hand, despite its technical challenges, arthroscopic grafting is thought to avoid complications by preserving surrounding tissues. (1) Do patients undergoing bone grafting via arthroscopy for scaphoid nonunion report better function than patients undergoing an open procedure? (2) Do patients undergoing bone grafting via arthroscopy for scaphoid nonunion demonstrate better objective outcomes, such as ROM, extremity strength, and bony union? Between January 2012 and January 2022, we operated on 141 patients with scaphoid nonunion. The following patients were excluded from this study: 33 patients with scaphoid nonunion advanced collapse and arthritis, 18 patients with proximal pole fractures, 5 patients with previous surgeries, 16 patients with avascular necrosis, and 8 patients with the radius used as a graft source. In total, 28 patients underwent open grafting, and 33 patients underwent arthroscopic grafting; for both groups, the iliac crest was used as the graft source. Two patients with nonunion were observed in each treatment group, and they were excluded from the study. Results from the remaining 26 patients treated with open grafting and 31 patients treated with arthroscopic grafting (totaling 57 patients) were analyzed. The decision to treat patients with open or arthroscopic methods was not based on a particular reason. In our clinic, we initially preferred open grafting for treating nonunion of the scaphoid. Subsequently, we began to prefer arthroscopic methods for the treatment of these injuries. Twenty patients in the arthroscopic group had additional ligamentous injuries, which were simultaneously treated arthroscopically. All patients in both groups had at least 1 year of follow-up, but 48% of patients treated arthroscopically and 42% of those treated with open approaches were lost before 2 years of follow-up. The remaining patients had follow-up periods longer than 24 months. Our primary analysis was performed at 1 year, and we did a secondary analysis at 2 years. We compared the Patient-Rated Wrist Evaluation (PRWE), QuickDASH, and VAS scores of the patients. We also compared ROM and grip and pinch strength in patients' contralateral wrists. We used predefined, evidence-based thresholds for the minimum clinically important differences for these outcome measures. According to the 1-year functional analysis, we found no clinically important difference between the open surgery group and the arthroscopic surgery group in terms of PRWE score (median [IQR] 19 [25] versus 8 [9], difference of medians 11; p = 0.001), QuickDASH (median 14 [23] versus 7 [11], difference of medians 7; p = 0.004), and VAS scores (median 2 [2] versus 1 [1], difference of medians 1; p = 0.02). At 1 year, there were no differences in objective measurements, including grip strength (median 81 [16] versus 85 [14], difference of medians 4; p = 0.60), pinch strength (median 82 [18] versus 81 [15], difference of medians 1; p = 0.85), and ROM (flexion-extension median 83 [22] versus 85 [13], difference of medians 2; p = 0.74; radial deviation-ulnar deviation median 80 [36] versus 85 [14], difference of medians 5; p = 0.61). In the 2-year analysis, no clinically important difference was observed in terms of PRWE score, and no differences were found in terms of QuickDASH, VAS, strength tests, and ROM between the open and arthroscopic groups. No difference was observed in the union rates between the open group and the arthroscopic group (93% [26 of 28] versus 94% [31 of 33], OR 1.19 [95% CI 0.16 to 9.06]; p = 0.86). In comparing open surgical procedures with arthroscopic techniques for the treatment of scaphoid nonunions, the present study revealed no differences in functional outcomes and objective measures such as ROM and strength tests at both the 1-year and 2-year follow-up visits. Although technically more challenging, arthroscopy provides a potential advantage, such as addressing concomitant ligament injuries simultaneously. However, patients did not perceive a difference between the two surgical methods. In future studies, investigating long-term outcomes in a larger population will contribute to better elucidating this issue. Level III, therapeutic study.

The outcome of nonoperative treatment for adult humeral shaft fractures using a U-shaped slab in resource-limited settings: a prospective cohort study

BackgroundHumeral shaft fractures, constituting 3–5% of musculoskeletal injuries, are commonly managed conservatively using functional braces. However, this approach may not be feasible in resource-limited settings. This study aimed to evaluate the functional outcomes of nonoperative treatment for humeral shaft fractures in adults utilizing a U-shaped slab.MethodsThis prospective study was conducted from August 2021 to August 2022 involving 16-year-old and older individuals who received nonsurgical treatment for humeral shaft fractures at public tertiary hospitals in Rwanda. The assessment focused on various functional outcomes, including alignment, union rate, range of motion, return to activities of daily living, and DASH score.ResultsThe study included 73 participants, predominantly males (73.9%), with a median age of 33 years. The union rate was high at 89.04%, and 10.96% experienced delayed union. Radial nerve palsy occurred in 4.11% of patients, but all the patients fully recovered within three months. Despite angular deformities during healing in the majority of participants, these deformities did not significantly impact functional outcomes. According to the international classification of disabilities, 77% of participants achieved a good functional grade.ConclusionThe conservative U-shaped slab method was effective at managing humeral shaft fractures. However, optimal results necessitate careful participant selection and comprehensive rehabilitation education. Implementing these measures can improve the overall success of nonoperative management.