Management of complete intra-articular distal femur and patellar fractures in an achondroplastic young adult; small is challenging' revisited: a case-report.

BACKGROUND: People with achondroplasia exhibit distinct physical characteristics, but their cognitive abilities remain within the normal range. The challenges encountered during surgical procedures and perioperative care for achondroplastic individuals, are underrepresented in the existing literature. CASE PRESENTATION: In this report, the management of a 26-year-old North-African achondroplastic male is highlighted. The patient suffered a complete intra-articular distal femur fracture (AO/OTA 33-C1) and an ipsilateral patella fracture (AO/OTA 34-C1). The patient's unusual anatomical variations and the lack of suitable orthopedic implants posed significant surgical challenges, particularly in the context of a resource-limited developing country. Facial and spinal deformities, which are common in patients with achondroplasia, further complicated the anesthetic approach. CONCLUSIONS: The limited information on operative management of fractures in achondroplastic patients necessitated independent decision-making and diverging from the convenient approach where clear guidance is available in the literature.

Traumatic Floating Total Hip Arthroplasty: A Case Report.

CASE: A 58-year-old woman with medical history of a left total hip arthroplasty performed by the direct anterior (DA) approach 2 years prior presented with left hip pain. She was found to have sustained a transverse Vancouver C periprosthetic femur fracture and an unstable periprosthetic pelvic fracture. CONCLUSIONS: This patient's case represents a previously not reported injury about a total hip arthroplasty-with disruption distal to the femoral implant and proximal to the acetabular implant, with the implant-to-bone interface unaffected. This case may guide future treatment of similar injuries.

Medial Hoffa Fracture: A Case Report and Literature Review of Approach and Management.

BACKGROUND Hoffa fractures are an uncommon form of coronal fracture that impact the femoral condyle. As a result, they are not very prevalent. It is necessary to perform anatomical reduction and rigorous fixation on these fractures; however, there is no consensus among medical professionals on the surgical procedure and implant that would be the most successful in treating these fractures. CASE REPORT A 50-year-old woman who had poliomyelitis in her right lower limb presented with a displaced medial Hoffa fracture of her left knee. She had fallen and was suffering from poliomyelitis. The trauma that caused this fracture had a modest energy level. Open reduction and internal fixation with 2 retrograde cannulated screws were included in her surgical procedure. An approach known as the medial parapatellar route was used for this treatment. As part of her postoperative rehabilitation, she participated in physiotherapy, exercises that did not require weight bearing, exercises that used passive and active assistance, activities that involved partial and full weight bearing, and exercises that involved complete weight bearing. At the 2-year follow-up, the patient's left knee continued to be painless and stable, and it had unrestricted range of motion across the whole extremity. It was determined via radiographs that the fracture had healed without any problems or arthritic changes developing. She was able to walk without help and carry out her daily tasks since she was able to walk with the use of a cane. CONCLUSIONS Retrograde cannulated screws can be a reliable and successful choice for treatment of medial Hoffa fractures, with positive results according to both clinical and radiographic characteristics. Further research is needed to analyze the outcomes over a longer period of time and make comparisons between this technique and others.

Numerical evaluation of internal femur osteosynthesis based on a biomechanical model of the loading in the proximal equine hindlimb.

Femoral fractures are often considered lethal for adult horses because femur osteosynthesis is still a surgical challenge. For equine femur osteosynthesis, primary stability is essential, but the detailed physiological forces occurring in the hindlimb are largely unknown. The objective of this study was to create a numerical testing environment to evaluate equine femur osteosynthesis based on physiological conditions. The study was designed as a finite element analysis (FEA) of the femur using a musculoskeletal model of the loading situation in stance. Relevant forces were determined in the musculoskeletal model via optimization. The treatment of four different fracture types with an intramedullary nail was investigated in FEA with loading conditions derived from the model. The analyzed diaphyseal fracture types were a transverse (TR) fracture, two oblique fractures in different orientations (OB-ML: medial-lateral and OB-AP: anterior-posterior) and a "gap" fracture (GAP) without contact between the fragments. For the native femur, the most relevant areas of increased stress were located distally to the femoral head and proximally to the caudal side of the condyles. For all fracture types, the highest stresses in the implant material were present in the fracture-adjacent screws. Maximum compressive (-348 MPa) and tensile stress (197 MPa) were found for the GAP fracture, but material strength was not exceeded. The mathematical model was able to predict a load distribution in the femur of the standing horse and was used to assess the performance of internal fixation devices via FEA. The analyzed intramedullary nail and screws showed sufficient stability for all fracture types.

Tumour-induced osteomalacia: the long road to diagnosis and recovery.

Tumour-induced osteomalacia is caused by tumorous production of fibroblast growth factor 23 (FGF23) leading to urinary phosphate wasting, hypophosphataemia and decreased vitamin D activation. The resulting osteomalacia presents with muscle weakness and bone pain but progresses to multiple pathological fractures. Patients often remain undiagnosed for years with severe physical, psychological and economic ramifications. A young woman presented with multiple spontaneous fractures including bilateral femoral fractures. Laboratory tests revealed severe hypophosphataemia, elevated bone turnover markers and low to normal calcium and 25-hydroxy-vitamin D levels. Treatment with phosphate, alfalcalcidol, calcium and magnesium was initiated. 68Gallium-DOTATOC positron emission tomography imaging revealed a mass in the right foot and venous sampling of FGF23 from all extremities confirmed this tumour as the culprit. Biopsy and histology were consistent with a phosphaturic mesenchymal tumour, which was surgically resected. Phosphate levels quickly normalised postoperatively but a long convalescence with hungry bone syndrome, fracture healing and physical therapy followed.

External fixator versus elastic stable intramedullary nail for treatment of metaphyseal-diaphyseal junction fractures of the pediatric distal femur: a case-control study.

BACKGROUND: Several methods have been used for the treatment of pediatric distal femoral fractures, such as elastic stable intramedullary nail (ESIN), external fixator (EF) and plate osteosynthesis, but there has been no consensus about the optimal method. The purpose of this study was to compare the clinical outcome between EF and ESIN techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal femur. METHODS: We retrospectively analyzed operatively treated MDJ fractures of pediatric distal femur between January 2015 and January 2022. Patient charts were reviewed for demographics, injury and data of radiography. All of the patients were divided into EF and ESIN groups according to the operation techniques. Malalignment was defined as more than 5 degrees of angular deformity in either plane. Clinical outcomes were measured by Flynn scoring system. RESULTS: Thirty-eight patients were included in this study, among which, 23 were treated with EF, and 15 with ESIN. The mean follow-up time was 18 months (12-24 months). At the final follow-up, all of the fractures were healed. Although there were no statistical differences between the two groups in demographic data, length of stay, estimated blood loss (EBL), rate of open reduction, time to fracture healing and Flynn score, the EF was superior to ESIN in operative time, fluoroscopic exposure and time to partial weight-bearing. The EF group had a significantly higher rate of skin irritation, while the ESIN had a significantly higher rate of malalignment. CONCLUSION: EF and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal femur. ESIN is associated with lower rates of skin irritation. However, EF technique has the advantages of shorter operative time, reduced fluoroscopic exposure, and shorter time to partial weight-bearing, as well as lower incidence of malalignment. LEVEL OF EVIDENCE: Level III.

Finite element analysis of the stability of retrograde intramedullary nail and plate-screw combinations for periprosthetic femoral fractures following total knee replacement.

OBJECTIVE: Periprosthetic fractures following total knee replacement are rare but challenging. The goal of the treatment is to achieve the most stable fixation that allows early mobilization. Therefore, the aim of this study was to evaluate the biomechanical results of the use of different fixation systems in the treatment of distal femur periprosthetic fractures with finite element analysis. MATERIALS AND METHODS: A total knee prosthesis was implanted in Sawbone femur models. A transverse fracture line was created in the supracondylar region and was fixed in four different groups. In group 1, fracture line fixation was fixed using retrograde intramedullary nailing. In group 2, fixation was applied using a lateral anatomic distal femoral. In group 3, in addition to the fixation made in group 1, a lateral anatomic distal femoral plate was used. In group 4, in addition to the fixation made in group 2, a 3.5 mm Limited Contact Dynamic Compression Plate (LC-DCP) was applied medially. Computed Tomography (CT) scans were taken of the created models and were converted to three-dimensional models. Axial and rotational loading forces were applied to all the created models. RESULTS: The least deformation with axial loading was observed in the double plate group. Group 3 was determined to be more advantageous against rotational forces. The greatest movement in the fracture line was found in group 2. The application of the medial plate was determined to reduce the tension on the lateral plate and increase stability in the fracture line. CONCLUSIONS: Combining a lateral anatomic plate with intramedullary nailing or a medial plate was seen to be biomechanically more advantageous than using a lateral plate or intramedullary nailing alone in the treatment of distal femoral periprosthetic fractures.

Clinical differences between periprosthetic and native distal femur fractures: a comparative observational study.

INTRODUCTION: The incidence of periprosthetic distal femur fractures (PDFF) is increasing as the number of total knee replacements becomes more common. This study compared the demographics, fracture characteristics, treatment, and outcomes of periprosthetic versus native distal femur fractures (NDFF). MATERIALS AND METHODS: This was a retrospective cohort study of patients ≥ 18 who underwent surgical fixation of NDFF or PDFF from 2012 to 2020 at a level-1 trauma center. The main variables collected included demographics, AO/OTA fracture classification, fixation construct, concomitant fractures, polytrauma rates, bone density, and reduction quality. Primary outcomes were unexpected return to the operating room (UROR), hospital length of stay, and quality of reduction. T-tests, Fisher's exact tests, and multivariate analyses were used for statistical analysis. RESULTS: 209 patients were identified, including 70 PDFF and 139 NDFF. PDFF patients were elderly females (81%) with isolated (80%) and comminuted (85%) 33 A.3 (71%) fractures. NDFF patients included 53% females, were commonly middle-aged, and displayed comminuted (92%) 33 C.2 fractures. 48% of NDFF patients had concomitant fractures. Intramedullary nailing was the primary fixation for both groups, followed by nail-plate combination (37%) for PDFF and lateral locking plates (21%) for NDFF. NDFF patients experienced significantly longer hospital stays, higher UROR rates, and worse quality of reduction (p < 0.05). PDFF patients had a significantly greater prevalence of low bone density (p < 0.05). CONCLUSION: PDFF occur as isolated injuries with significant metaphyseal comminution in elderly females with low bone quality. NDFF commonly occurs in younger patients with less metaphyseal comminution and concomitant fractures. Intramedullary nailing was the most common treatment for both groups, although preference for nail-plate combination fixation is increasing. NDFF type 33 C fractures are at greater risk of UROR.

Fracture healing on non-union fracture model promoted by non-thermal atmospheric-pressure plasma.

Non-thermal atmospheric-pressure plasma (NTAPP) is attracting widespread interest for use in medical applications. The tissue repair capacity of NTAPP has been reported in various fields; however, little is known about its effect on fracture healing. Non-union or delayed union after a fracture is a clinical challenge. In this study, we aimed to investigate how NTAPP irradiation promotes fracture healing in a non-union fracture model and its underlying mechanism, in vitro and in vivo. For the in vivo study, we created normal and non-union fracture models in LEW/SsNSlc rats to investigate the effects of NTAPP. To create a fracture, a transverse osteotomy was performed in the middle of the femoral shaft. To induce the non-union fracture model, the periosteum surrounding the fracture site was cauterized after a normal fracture model was created. The normal fracture model showed no significant difference in bone healing between the control and NTAPP-treated groups. The non-union fracture model demonstrated that the NTAPP-treated group showed consistent improvement in fracture healing. Histological and biomechanical assessments confirmed the fracture healing. The in vitro study using pre-osteoblastic MC3T3-E1 cells demonstrated that NTAPP irradiation under specific conditions did not reduce cell proliferation but did enhance osteoblastic differentiation. Overall, these results suggest that NTAPP is a novel approach to the treatment of bone fractures.

Comparative Outcomes of Elastic Stable Intramedullary Nailing vs. Plate Fixation in Pediatric Femoral Shaft Fractures. A Prospective Study.

BACKGROUND: Pediatric femoral fractures are common in emergency rooms, with treatment options varying by age. This study compares elastic stable intramedullary nailing (ESIN) and plate fixation for diaphyseal femoral fractures in children aged 5-10. MATERIAL AND METHODS: Conducted at Al-Kindi Teaching Hospital, Baghdad, from December 2017 to December 2019, this prospective study included 32 children with closed transverse diaphyseal femoral fractures. Patients were divided into two groups: 16 treated with ESIN (Group 1) and 16 with plate fixation (Group 2). Criteria excluded comminuted, open, or pathological fractures. RESULTS: Group 1 had a mean age of 7.1 years and weight of 23.7 kg; Group 2 had a mean age of 7.8 years and weight of 30.9 kg. ESIN resulted in shorter operative times (58.4 minutes), earlier weight-bearing, and quicker fracture union (8.8 weeks) compared to plate fixation (76.3 minutes, 11.9 weeks). Blood loss was significantly less in Group 1 (32.8 ml) versus Group 2 (205.0 ml). No significant differences in wound healing or leg length discrepancies were observed. CONCLUSIONS: 1. Our study indicates a preference for Elastic Stable Intramedullary Nailing (ESIN) over plate fixation for pediatric femoral shaft fractures in children aged 5-10 years. 2. ESIN is associated with shorter operative times and faster commencement of weight-bearing, critical in pediatric recovery. 3. While ESIN is generally preferable, plate fixation may be better suited in certain clinical scenarios, emphasizing the importance of personalized treatment. 4. Based on our findings, ESIN is recommended for treating transverse diaphyseal femur fractures in the specified pediatric age group. 5. Recommends further studies, including randomized controlled trials, for a more comprehensive understanding of these treatments' long-term outcomes.

Treatment of Length-Unstable Pediatric Femur Fractures in Children Aged 5 to 11 years: A Focused Review.

Pediatric femur fractures in children aged 5 to 11 years are typically classified as length-stable versus length-unstable. For length-stable fracture patterns, there is frequent consensus among pediatric orthopaedic specialists regarding the appropriateness of flexible intramedullary nails, submuscular plates (SMP), or lateral-entry rigid intramedullary nails (LE-RIMN). With length-unstable fracture patterns, however, the decision is more complex. Age, weight, fracture pattern, fracture location, surgical technique, surgeon experience, several implant-specific details, and additional factors are all important when choosing between flexible intramedullary nail, SMP, and LE-RIMN. These familiar methods of fixation may all be supported by conflicting and sometimes heterogeneous data. When planning to treat length-unstable fractures in young children, surgeons should understand evidence-based details associated with each implant and how each patient-specific scenario affects perioperative decisions.

Radiographic outcomes and non-union factor analysis in fragmentary segmental femoral shaft fractures (AO/OTA 32C3) treated with reamed antegrade nailing.

This study retrospectively assessed radiographic outcomes and risk factors associated with non-union in femoral shaft fragmentary segmental fractures (AO/OTA 32C3) treated with reamed antegrade intra-medullary nailing. Radiological outcomes, including union and alignment, were evaluated. The risk factors for non-union were investigated, including demographics and treatment-related characteristics, such as the number of interlocking screws, segmentation length, main third fragment length, distance of the main third fragment, width ratio and exposed nail length in one cortex from immediate post-operative radiographs. Multivariate logistic regression was used for statistical analysis. Among 2295 femoral shaft fracture patients from three level-1 trauma centers, 51 met the inclusion criteria. The radiological union was achieved in 37 patients (73%) with a mean union time of 10.7 ± 4.8 months. The acceptable axial alignment was observed in 30 patients (59%). Multiple logistic regression analysis identified only exposed nail length as a significant risk factor for non-union (odds ratio: 1.599, p = 0.003) and the cut-off value was 19.1 mm (sensitivity, 0.786; specificity, 0.811). The study revealed high rates of non-union (27%) and malalignment (41%). Therefore, patients who underwent intramedullary nailing with an exposed nail length greater than 19.1 mm or about twice the nail diameter should be cautioned of the potential non-union.

Correction of Equinus Deformity by Ilizarov Frame Using the Matsushita Method and Achilles Tendon Lengthening: A Case Report.

CASE: The patient was an 18-year-old man who had sustained diaphyseal fractures of the left femur and tibia in a traffic accident and underwent surgery at another hospital. A severe left foot equinovarus deformity developed in the early after surgery. The patient's left foot deformity was addressed using unconstrained gradual external fixator correction (the Matsushita method) in combination with soft-tissue contracture through Achilles tendon lengthening and was maintained after removing the external fixation. CONCLUSION: The Matsushita method can be effective in the correction of post-traumatic equinovarus foot deformities.

Risk factors for femoral stem fracture following total hip arthroplasty: a systematic review and meta analysis.

BACKGROUND: Femoral stem fracture following total hip arthroplasty (THA) is an infrequent but nevertheless devastating complication, with an increasing worldwide prevalence as demand for primary THA continues to increase. The aim of this study was to perform a systematic review and meta-analysis of risk factors for femoral stem fracture to help identify at risk patients. METHODS: A systematic search was conducted on EMBASE, MEDLINE and AMED to identify relevant studies. Data regarding study design, source, population, intervention, and outcomes was collated. Data extraction was performed on a custom form generated using Cochrane recommended methodology and analysis of risk factors performed including odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: A total of 15 studies reporting a total of 402 stem fractures in 49 723 THAs were identified. The median time from index procedure to stem fracture was 68 months (IQR 42.5-118) whilst mean age at index surgery was 61.8 years (SD 6.9). Male gender (OR = 3.27, 95% CI = 2.59-4.13, p < 0.001), patient weight above 80 kg (OR = 3.55, 95% CI = 2.88-4.37, p < 0.001), age under 63 years (OR = 1.22, 95% CI = 1.01-1.49, p < 0.001), varus stem alignment (OR = 5.77, 95% CI = 3.83-8.7, p < 0.001), use of modular implants (OR = 1.95, 95% CI = 1.56-2.44, p < 0.01) and undergoing revision arthroplasty (OR = 3.33, 95% CI = 2.70-4.1, p < 0.001) were significant risk factors for prosthetic stem fracture. A risk window of 15 years post-surgery was identified. CONCLUSIONS: This review concludes that patient weight, younger age, male sex, varus stem alignment, revision arthroplasty and use of modular stems are significant risk factors for femoral stem fracture. Modifying these risk factors where possible may help reduce incidence of femoral stem fracture in at risk patients.

Principles of Minimally Invasive Reduction and Nail Fixation for Subtrochanteric Femur Fractures.

Subtrochanteric femur fractures have a reputation as difficult orthopaedic injuries to treat. Strong deforming forces, including the hip musculature and high physiologic forces, must be counteracted to obtain and maintain reduction. Adding to the complexity is a wide variety of fracture morphologies that must be recognized to execute an appropriate surgical plan. The challenging nature of this injury is demonstrated by nonunion rates of 4% to 5%, but some series have reports of up to 15% and malunion rates of 10% to 15%. Improved outcomes have been shown to be dependent on appropriate reduction and stable fixation, which can be achieved with less surgical insult. The treating surgeon must have a thorough understanding of the injury characteristics and reduction techniques to appropriately execute minimally invasive techniques for these difficult fractures.

[Treatment of open fracture bone defect of distal femur with antibiotic cement column and bone graft].

OBJECTIVE: To investigate the efficacy of antibiotic cement column combined with iliac bone graft in the treatment of open fracture with bone defect of distal femur. METHODS: From October 2014 to March 2021, 16 patients of open fracture bone defect of distal femur were treated with antibiotic bone cement column and iliac bone graft, including 12 males and 4 females. The age ranged from 28 to 68 years old. There were 11 cases of traffic accident injury, 5 cases of falling injury, 3 cases as Gustilo type Ⅰ, 5 cases as type Ⅱ and 8 cases as type ⅢA. AO classification was used:9 cases of C2 type and 7 cases of C3 type. The time from injury to final bone grafting ranged from 4 to 119 days. The length of bone defect ranged from 2 to10 cm. Fractures healing time, complications and knee function Merchan score were recorded. RESULTS: All the 16 patients were followed up from 9 to 29 months. The incisions of 16 patients healed in one stage without postoperative infection, plate fracture, limb shortening and valgus and varus deformity. The healing time randed from 4 to 10 months . Knee joint function according to the Merchant scoring standard, showed that 8 cases were excellent, 4 cases were good, 3 cases were fair, and 1 case was poor. CONCLUSION: The use of antibiotic bone cement column combined with iliac bone graft in the treatment of open and complex bone defects of distal femur is an effective surgical method to prevent infection, assist fracture reduction, increase fixation strength and significantly reduce the amount of bone grafting.

[National competitive bidding analysis of osteosynthesis materials in pediatric patients with femur fractures]. / Análisis de licitación pública nacional de materiales de osteosíntesis en los pacientes pediátricos con fracturas de fémur.

INTRODUCTION: health promotion policy requires the identification of barriers to the adoption of public policies. Paraguay's national healthcare system is inequitable, expensive, and inefficient. The Ministry of Public Health and Social Welfare (MSPyBS) is the entity responsible for covering the needs of a significant portion of the population. In January 2022, the MSPyBS financed the purchase of titanium elastic nails through a National Public Tender for Osteosynthesis Materials (LPN 02/22) to provide them for free in the pediatric service. Using research as a tool, we seek to analyze the impact of the implementation of LPN 02/22 at the Trauma Hospital, believing that this action would help streamline administrative and bureaucratic processes, making them more efficient with the assistance of the hospital's human resources. MATERIAL AND METHODS: a retrospective, analytical, and comparative study conducted at a high-complexity trauma center in Asunción, Paraguay. Patients aged 4 to 14 years with an indication for stabilization with elastic nails were included. Demographic data, the mechanism of injury, time elapsed from hospital arrival to surgical treatment, length of hospital stay, and the average hospital cost were analyzed based on the daily expense of pediatric patient hospitalization. RESULTS: 52 patients, divided into 25 cases in 2021 before implementation and 27 cases after implementation. The time elapsed from hospital arrival to definitive treatment was six days in the pre-implementation period, with an average stay from admission to discharge of 7.4 days. After implementation, the time from hospital arrival to definitive treatment was 4.3 days, and the average discharge time for the Post group was six days. The potential savings per patient amount to 332 dollars, offset by the institution's implant supply cost of 197 dollars, resulting in an approximate savings of 135 dollars per patient for the ministry. CONCLUSIONS: we view the implementation of free titanium elastic nails for pediatric femur fracture patients positively. We encourage the institution to continue with similar policies and strive to achieve even greater benefits for users.

INTRODUCCIÓN: la política de promoción de la salud requiere la identificación de los obstáculos para la adopción de políticas públicas. El sistema nacional de salud de Paraguay es inequitativo, caro e ineficiente. El Ministerio de Salud Pública y Bienestar Social (MSPyBS) es el ente que cubre las necesidades de gran parte de la población. El MSPyBS en Enero del 2022 financió, mediante la Licitación Pública Nacional de Materiales de Osteosíntesis (LPN 02/22), la compra de clavos elásticos de titanio para disponer de su uso gratuito en el Servicio de Pediatría; usando a la investigación como herramienta, buscamos analizar el impacto de la implementación de la LPN 02/22 en el Hospital de Trauma, creyendo que esta acción ayudaría a dinamizar los procesos administrativos y burocráticos, haciéndolos más eficientes con la ayuda de los recursos humanos del hospital. MATERIAL Y MÉTODOS: estudio retrospectivo, analítico y comparativo, realizado en un centro de trauma de alta complejidad de Asunción, Paraguay. Fueron incluidos los pacientes con edad comprendidas entre cuatro y 14 años, con indicación de estabilización con clavos elásticos. Se analizaron los datos demográficos, el mecanismo de trauma, el tiempo transcurrido desde la llegada al hospital hasta el tratamiento quirúrgico, así como el tiempo de estadía hospitalaria. Se evaluó el costo hospitalario promedio, basados en el gasto diario de la internación de un paciente pediátrico. RESULTADOS: cincuenta y dos pacientes, separados en 25 casos en el 2021 previo a la implementación y 27 casos posterior a la implementación. El tiempo transcurrido desde la llegada al hospital hasta el tratamiento definitivo fue de seis días para la etapa previa a la implementación; el promedio desde el ingreso hasta el alta fue de 7.4 días. Desde la implementación se tuvo un transcurso de 4.3 días desde la llegada al hospital hasta el tratamiento definitivo. El egreso del grupo Post tuvo un promedio de seis días. El ahorro probable en relación con cada paciente es de 332 dólares; a esto debemos contrarrestar el monto que paga la institución para la provisión del implante (197 dólares), por lo que el ahorro del ministerio sería de aproximadamente 135 dólares por cada paciente. CONCLUSIONES: vemos como positiva la implementación de la gratuidad de los clavos elásticos de titanio en los pacientes en edad pediátrica con fractura de fémur. Alentamos a la institución a seguir con políticas similares y tratar de lograr mayores beneficios para los usuarios.

Posterior Cruciate Ligament Injury After Retrograde Nailing of Periprosthetic Distal Femur Fractures: A Report of 2 Cases.

CASE: A 51-year-old man and 64-year-old woman with bilateral cruciate-retaining total knee arthroplasties (CR-TKAs) who sustained unilateral periprosthetic distal femur fractures above their CR-TKA and experienced knee instability secondary to an iatrogenic posterior-cruciate-ligament (posterior cruciate ligament [PCL]) injury from retrograde intramedullary nailing. Both patients recovered knee stability after undergoing revision surgery. CONCLUSION: Many CR-TKA designs have sufficient medial-lateral intercondylar distance to place a retrograde nail, femoral components with a relatively posterior transition from the trochlear groove to the intercondylar box will necessitate a nail starting point closer to the PCL origin. This may contribute to iatrogenic postoperative knee instability for patients with CR-TKA designs.

Evaluation of the mechanical behaviour of the expandable wedge locked nail fixation in retrograde use: A finite element study.

INTRODUCTION: In literature, there have been many studies conducted to research the alternatives of standard interlocking intramedullary nailing. The expandable wedge locked nail fixation, which is thought as a new alternative to the standard interlocking nailing, has been presented in previous numerical studies. The antegrade usage of the wedge locked nail fixation has provided promising results. From this point, the aim of the study is to evaluate mechanical behavior of its retrograde usage on femur models. Additionally, another aim of the study is to investigate the effect of fracture level on mechanical properties of the fixation. MATERIALS AND METHODS: The mechanical behaviors of the wedge locked nail and standard interlocking nail fixations were compared by finite element methods. Sawbones femurs having osteotomies at five different levels to simulate different fractures were fixed with wedge locked nail or interlocking nail by using retrograde approach. With respect to the fracture level, two different nail lengths were used. Axial compression load was applied to fixations. The mechanical behaviors of the fixations were evaluated with respect to stiffness of the fixations and stresses occurred on both implants and bones. RESULTS: Any of the wedge locked nail fixation did not slip at canal. The stress and stiffness results were mostly close with each other for both nail types. The maximum stresses at locking elements or bones contacting these elements increased with decreased distance between the fracture and relevant locking elements. DISCUSSION: The wedge locked nail fixation showed comparable results to the standard interlocking nail fixation with respect to the stiffness and stress. Under axial loading, wedge locked nail provided a secured fixation without any slippage and preserved its position inside the medullary canal. It may be thought as a safe alternative to the standard interlocking nail fixation for retrograde usage. Additionally, according to stress results, it is advised to the surgeons to avoid a close locking to the fracture line.

Unravelling variations: an examination of entry point selection in proximal femoral cephalomedullary nailing.

BACKGROUND: The exact positioning of the cephalomedullary (CM) nail entry point for managing femoral fractures remains debatable, with significant implications for fracture reduction and postoperative complications. This study aimed to explore the variability in the selection of the entry point among trauma surgeons, hypothesizing potential differences and their association with surgeon experience. METHODS: In this prospective multicenter study, 16 participants, ranging from residents to senior specialists, partook in a simulation wherein they determined the optimal entry point for the implantation of a proximal femoral nail antirotation (PFN-A; DePuy Synthes) in various femora. The inter- and intra-observer variability was calculated, along with comprehensive descriptive statistical analysis, to assess the variability in entry point selection and the impact of surgeon experience. RESULTS: In this study, the mean distance from the selected entry points to the calculated mean entry point was 3.98 mm, with a smaller distance observed among surgeons with more than 500 implantations (ANOVA, p = 0.050). Intra-surgeon variability for identical femora averaged at 5.14 mm, showing no significant differences across various levels of surgical experience or training. Notably, 13.6% of selected entry points would not allow a proper intramedullary positioning of the implant, thereby rendering anatomical repositioning unfeasible. Among these impossible entry points, a significant skew towards anterior placement was observed (70.6% of the impossible entry points), with a smaller fraction being overly lateral (27.5%) or medial (13.7%). On a patient level, the impossibility rate varied widely from 0 to 35% among the different femora examined, with a significantly higher rate seen in younger patients (mean age 55.02 versus 60.32; t-test for independent samples, p = 0.04). CONCLUSIONS: Significant variations exist in surgeons' selection of entry points for proximal femoral nailing, underscoring the task's complexity. Experience does not prevent the choice of unfeasible entry points, emphasizing the inadequacy of a universal approach and pointing towards the necessity for a patient-specific strategy for improved outcomes. TRIAL REGISTRATION NUMBER: DRKS00032465.