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.

Is Elastic Stable Intramedullary Nailing a Viable Treatment Option for Diaphyseal Fractures of the Humerus in Adults? A 29-case Series Prospective Study.

BACKGROUND: Humerus shaft fractures are common in orthopaedic practice. The emphasis in treatment has shifted from prolonged immobilisation to early mobilisation and internal fixation when needed for a quicker return to normal function. Internal fixation methods include plate osteosynthesis and intramedullary nailing. This study specifically evaluated the effectiveness of flexible intramedullary nails in treating diaphyseal humeral fractures. MATERIAL AND METHODS: Between April 2007 and January 2010, Alexandria University Hospital treated 29 patients (21 males, 8 females) with diaphyseal humeral fractures. Treatment involved closed reduction and percutaneous fixation using two flexible nails. Patients, aged 17 to 65 with a mean age of 32, were included if they did not have pathological fractures, were above 16 years old, and were medically suitable. Causes included pedestrian vehicle accidents (17 cases) and falls or sports-related activities (12 cases). Surgical intervention occurred 1 to 8 days after the injury. RESULTS: Between April 2007 and January 2010, Alexandria University Hospital treated 29 patients (21 males, 8 females) for diaphyseal humeral fractures using closed reduction and percutaneous fixation with two flexible nails. Patients, aged 17 to 65, were monitored for an average of 18 months. Radiographic assessments showed complete union in nineteen fractures within 13 to 21 weeks. One patient experienced non-union but was successfully treated with bone grafting and plating. There were no significant intraoperative complications. Notably, four patients with preoperative radial nerve injuries recovered within 6 to 8 weeks. Evaluation using the Stewart and Hundley Scoring technique showed excellent outcomes for 60% of patients, good outcomes for 30%, fair outcomes for 5%, and poor outcomes for 5%. CONCLUSIONS: 1.The Elastic Stable Intramedullary Nailing (ESIN) technique shows promise in the treatment of humeral shaft fractures. 2. However, the success of treatment may depend on various factors, including patient age, fracture characteristics, and the presence of complications such as open fractures and radial nerve palsy. 3. Careful consideration of these factors is necessary when selecting a treatment approach for humeral shaft fractures.

Feline radial and ulnar diaphyseal fractures: a retrospective study of 49 cases comparing single bone fixation and dual bone fixation.

OBJECTIVES: The objectives of this study were to report the complications in radial and ulnar diaphyseal fractures in cats and to compare the differences in outcome between single and dual bone internal fixation. METHODS: Medical records between 2004 and 2022 were searched retrospectively for cats with antebrachial diaphyseal fractures treated with internal bone-plate fixation. In total, 49 cases were included from six referral hospitals, including one teaching hospital. Patient information was collated, including fracture configuration, location, repair method and clinical outcome as assessed by veterinary physical examination, radiography and owner questionnaire. RESULTS: A total of 47 cats (mean age 4.2 years) were included. Fractures were located distally (24/49, 49%), proximally (13/49, 26.5%) and mid-diaphyseally (12/49, 24.5%). Dual bone fixation was used in 13/49 (26.5%) cases, with only 1/13 (7.7%) having major complications. By comparison, 4/36 (11.1%) of single plated fractures had major complications. Single bone fixation was 14.25 times more likely (95% confidence interval [CI] 2.07-97.99) to have a successful outcome (veterinarian-assigned score of 0) compared with dual bone fixation (P = 0.007). When evaluating owner-assessed outcomes, single bone fixation was 9.4 times more likely (95% CI 1.4-61.96) to have a successful outcome (owner score of 0) compared with dual bone fixation (P = 0.019). CONCLUSIONS AND RELEVANCE: Fractures that were repaired with single bone fixation had a greater chance of a better outcome. Although the difference was not significant, there was a higher major complication rate and a lower minor complication rate for cases treated with single bone fixation compared with dual bone fixation. The majority of fractures were located in the distal diaphysis. Comminution of the fracture and concurrent orthopaedic issues did not significantly affect the outcome. Further prospective studies with standardised follow-up, radiographic assessment, surgeon and implants are required to truly assess the difference between dual and single bone fixation.

Adamantinoma of the Ulnar Shaft Reconstructed With a Vascularized Free Fibula.

We describe a 36-year-old man with a long-standing diagnosis of ulnar fibrous dysplasia with associated fracture of the ulna. He presented with a growing and increasingly tender forearm mass and was diagnosed with adamantinoma of the ulna, for which he underwent wide resection of the ulnar diaphysis followed by reconstruction with a vascularized fibula autograft. This case serves to emphasize the importance of performing a stepwise workup for the diagnosis of osseous neoplasms even in cases with long-standing diagnoses. [Orthopedics. 2024;47(2):e102-e105.].

Single versus double plate fixation of humeral shaft nonunion.

INTRODUCTION: Humeral shaft fractures are common fractures of the diaphysis of the humerus. The aim of this study was to evaluate factors affecting the clinical outcomes of humeral nonunions surgically treated with open reduction and single- versus double-plate fixation with grafting. MATERIALS AND METHODS: A total of 31 patients with nonunion treated with single- or double-plate screw fixation with bone grafting were retrospectively analysed. The patients were divided into two groups according to the treatment method as Group 1 (single-plate, n = 14) and Group 2 (double-plate, n = 17). Data including demographic and clinical characteristics of the patients, initial and final treatment, type of nonunion and localisation, graft use, shortening, follow-up, time to union, Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) scores, and patient-reported cosmetic outcomes were recorded. RESULTS: Of the patients, eight were males, and 23 were females, with a mean age of 47.6 ± 15.8 (range, 20-86) years. Initial treatment was conservative treatment (Sarmiento brace) in seven patients, plate fixation in 22 patients, and intramedullary nailing in two patients. The mean follow-up was 31.0 ± 16.9 months in Group 1 and 25.4 ± 15.6 months in Group 2. There was one nonunion in Group 1 and three in Group 2. There were no significant differences in the union rate and time to union (p = 0.378 and p = 0.262, respectively). The mean Quick-DASH scores and cosmetic results were similar between the groups (p = 0.423 and p = 0.165, respectively). Radial nerve palsy developed in three patients in Group 2, and all these patients recovered completely during follow-up. CONCLUSIONS: Although the double-plate fixation technique has similar clinical, radiological, and functional results to single-plate fixation, it is a more invasive and expensive technique with a longer operation time. Therefore, it should not be used as the first-line treatment option for all humeral shaft nonunion. Nevertheless, the double-plate technique may be preferred to achieve in cases requiring high stability, such as hypertrophic nonunion, osteopenia and comminuted fractures.

Tandem Reconstruction of the Femoral Diaphysis Using an Intercalary Prosthesis and a Fibular Free Flap.

BACKGROUND: Femoral diaphyseal reconstructions with metal prostheses have mediocre results because of high mechanical forces that result in eventual implant failure. Biological alternatives require prolonged restrictions on weight-bearing and have high rates of infection, nonunion, and fracture. A novel method of utilizing a vascularized fibula in combination with an intercalary prosthesis was developed to complement the immediate stability of the prosthesis with the long-term biological fixation of a vascularized fibular graft. METHODS: A prospectively maintained database was retrospectively reviewed to identify patients who underwent reconstruction of an oncological intercalary femoral defect using an intercalary prosthesis and an inline fibular free flap (FFF). They were compared with patients who underwent femoral reconstruction using an intercalary allograft and an FFF. RESULTS: Femoral reconstruction with an intercalary metal prosthesis and an FFF was performed in 8 patients, and reconstruction with an allograft and an FFF was performed in 16 patients. The mean follow-up was 5.3 years and 8.5 years, respectively (p = 0.02). In the bioprosthetic group, radiographic union of the fibula occurred in 7 (88%) of 8 patients, whereas in the allograft group, 13 (81%) of 16 patients had allograft union (p = 1.00) and all 16 patients had fibular union (p = 0.33). The mean time to fibular union in the bioprosthetic group was 9.0 months, whereas in the allograft group, the mean time to allograft union was 15.3 months (p = 0.03) and the mean time to fibular union was 12.5 months (p = 0.42). Unrestricted weight-bearing occurred at a mean of 3.7 months in the prosthesis group and 16.5 months in the allograft group (p < 0.01). Complications were observed in 2 (25%) of 8 patients in the prosthesis group and in 13 (81%) of 16 patients in the allograft group (p = 0.02). Neither chemotherapy nor radiation affected fibular or allograft union rates. Musculoskeletal Tumor Society scores did not differ significantly between the groups (mean, 26 versus 28; p = 0.10). CONCLUSIONS: Bioprosthetic intercalary femoral reconstruction with a metal prosthesis and an FFF resulted in earlier weight-bearing, a shorter time to union, fewer operations needed for union, and lower complication rates than reconstruction with an allograft and an FFF. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Femoral Neck Preservation and Diaphyseal Invasion Comparing a Calcar-Metaphyseal Short Stem with its Homonymous Standard Femoral Stem. A Radiographic Study.

BACKGROUND: We aim to compare the preoperative planning radiographs of 50 patients in whom both a short stem and its homonymous standard version were programmed, focusing on the preservation of the neck and the invasion of the femoral shaft. The secondary objective was to evaluate the 50 preoperative radiographs with the 50 postoperative radiographs in which the short stem was implanted, measuring the real invasion of the diaphysis and the real preservation of the femoral neck. MATERIAL AND METHODS: We measured cut level at the femoral neck and diaphyseal invasion in 50 preoperative x-rays where an Alteon Neck Preserving Stem (ANPS) was templated and we compared it with 50 preoperative x-rays where an Alteon Taper Wedge Stem (ATWS) was templated. After surgery, we compared both parameters previously measured in the preoperative x-rays with the 50 postoperative radiographs where the short stem was implanted obtaining the real bone preservation at the femoral neck and the real diaphyseal invasion length. RESULTS: For templating comparison, mean bone preservation at the femoral neck was 14.87mm (SD 3.64) for the ANPS group and 9.94mm (SD 8.39) for the ATWS group (p <0.001). The mean diaphyseal bone invasion was 47.21mm (SD 5.89) and 76.77mm (SD 8.39) for ANPS and ATWS respectively (p <0.001). After surgery, the mean postoperative bone preservation at the femoral neck was 15.08mm (SD 3.1) with a mean of 0.17mm (SD 0.51) more preservation in the preoperative group. CONCLUSION: 1. ANPS allow bone preservation with limited diaphyseal invasion when compared with his homonymous ATWS in the preoperative templates. 2. ANPS showed a good correlation between preoperative radiographs and real bone preservation of the femoral neck and invasion of the femoral shaft.

CT measurements of the proximal femoral medullary cavity in healthy adults: a cross-sectional study.

Objectives: To analyse the proximal femoral morphology on three-dimensional reconstructed imagery to explore the factors influencing the relevant parameters. METHODS: The cross-sectional study was conducted at Peking University Third Hospital in northern China from January 2019 to August 2020, and comprised healthy adults who underwent computed tomography scanning. Three-dimensional computed tomography reconstruction of the proximal femoral medullary cavity was performed using Mimics 22. The anatomical parameters related to total hip arthroplasty were measured to examine the relationship among gender, age and femoral length. Data was analysed using SPSS 20. RESULTS: Of the 63 adults, meaning 126 hips, 21(33.3%) were males, meaning 42 (33.3%) hips, and 42(66.6%) were females, meaning 84(66.6%) hips. The overall mean age was 51.5±23.1 years (range: 23-68 years). The inflection point of the medullary cavity curved at 5-10mm distal to the lesser trochanteric line. Most horizontal plane parameters significantly differed between men and women (p<0.05), with the mean medullary cavity being wider in men than women. There was a significant difference between the genders in the sagittal anterior-posterior diameter of the canal flare index (p<0.05). Age was negatively correlated with the coronal medial-lateral diameter and coronal lateral diameter of canal flare index. In the coronal and sagittal planes, there was a positive correlation between the metaphysis and diaphysis, and the coronal and sagittal planes were positively correlated with the orthogonal plane. CONCLUSIONS: Femoral morphology could be influenced by gender and age. Morphological changes of the proximal femoral medullary cavity were not present in a single plane, but were affected by multiple planes. When the diameter of one plane became larger, its orthogonal plane concomitantly increased.

Clinical Outcomes of Minimally Invasive Fixation with Pre-Bent Elastic Stable Intramedullary Nails for the Treatment of Distal Radius Metaphyseal Diaphysis Junction Fractures in Children.

OBJECTIVE: Although mini-plate fixation is an attractive treatment option for distal radius metaphyseal diaphysis junction (DRMDJ) fractures in children, the benefits of minimally invasive fixation (MIF) with pre-bent elastic stable intramedullary nails (MIF) remain underexplored. Therefore, this study aimed to evaluate the clinical efficacy of MIF administration in children with DRMDJ fractures. METHODS: This retrospective study enrolled 40 patients with DRMDJ fractures who underwent MIF or mini-plate fixation from January 2016 to January 2021. Radiographic parameters, such as palmar inclination and ulnar deflection angle, were examined postoperatively to assess the anatomical reduction of the wrist joint. Clinical outcomes, including the range of wrist flexion and back extension, were examined to analyze the recovery of the wrist range of motion. Additionally, the Gartland-Werley scoring system was used to assess the recovery status of wrist function and healing condition. The student t-test and χ2 test were used to compare differences among groups. RESULTS: All included patients successfully underwent the operation and were followed up for 12-24 months. Patients in the MIF group had a smaller surgical incision length (0.49 ± 0.06 cm) compared to those in the mini-plate fixation group (4.41 ± 0.73 cm) (t = 22.438, p = 0.000). Palmar inclination and ulnar deflection were within the normal range in patients of both groups, and the fractures were successfully anatomically reduced. Moreover, wrist flexion and back extension in the MIF group and mini-plate group were (72.50° ± 0.64° vs. 70.18° ± 0.56°) and (59.55° ± 1.75° vs. 60.04° ± 1.37°), and differences were statistically significant (t = 2.708, p = 0.010 and t = 0.885, p = 0.382, respectively). Furthermore, MIF treatment resulted in a higher proportion of excellent Gartland-Werley scores (94.44%) than mini-plate fixation (86.36%) (p = 0.390). In addition, one case in the mini-plate fixation group experienced re-fracture following the removal of the internal fixation, and the fracture healed after reduction and cast fixation. All patients achieved satisfactory bone healing without other complications. CONCLUSION: Compared with mini-plate fixation, MIF has the advantages of small incision length, superior range of motion of thr wrist joint, and better maintenance of the physiological radian, providing a promising approach for clinical and surgical treatment of DRMDJ fractures.

Comparison of intramedullary nailing and plate fixation in the surgical treatment of isolated fractures of the distal two-thirds of ulna diaphysis.

OBJECTIVES: This study aims to compare the clinical and radiological results of intramedullary nailing and plating, which are both techniques utilized frequently in the surgical treatment of isolated fractures of the distal third of the ulna diaphysis. PATIENTS AND METHODS: Between January 2010 and December 2016, a total of 54 patients (34 males, 20 females; mean age: 37.8±7.4 years; range, 22 to 56 years) with isolated fractures of the distal third of the ulna diaphysis were retrospectively analyzed. The patients were divided into those treated with locking plates (Plating group, n=25) and those treated with intramedullary nailing (IMN group, n=29). The operating time and clinical and radiological results were compared between the groups. RESULTS: The median follow-up time was 93 (range, 84.5 to 99.5) months in the Pg and 86 (range, 80 to 97) months in the IMNg (p=0.179). No significant difference was observed between the groups in respect of age, sex, trauma mechanism, fracture classification, smoking status, and time from trauma to surgery. The median operating time was 46 min in the Pg and 33 min in the IMNg (p<0.001). No significant difference was found in the postoperative length of stay in hospital, reduction quality, infection rates, clinical results, radiological results, and the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) score between the groups. Implant removal was only needed in the locking plate group (p=0.007). CONCLUSION: In the surgical treatment of isolated fractures of the distal third of the ulna diaphysis, locked IMN seems to be a good alternative to the plate method with a shorter operating time and less need for implant removal.

What Is the Prosthetic Survival After Resection and Intercalary Endoprosthetic Reconstruction for Diaphyseal Bone Metastases of the Humerus and Femur?

BACKGROUND: Large metastatic lesions of the diaphysis can cause considerable pain and result in difficult surgical challenges. Resection and cemented intercalary endoprosthetic reconstruction offer one solution to the problem, but it is an extensive operation that might not be tolerated well by a debilitated patient. The risk of aseptic loosening and revision after intercalary endoprosthetic replacement has varied in previous reports, which have not examined the risk of revision in the context of patient survival. QUESTIONS/PURPOSES: (1) In a small case series from one institution, what is the survivorship of patients after cemented intercalary endoprosthetic replacement for diaphyseal metastasis, and what is the cumulative incidence of revision for any reason? (2) What are the complications associated with cemented intercalary reconstruction? (3) What is the functional outcome after the procedure as assessed by the MSTS93 score? METHODS: We retrospectively studied 19 patients with diaphyseal long bone metastases who were treated with resection and cemented intercalary endoprosthetic reconstruction by five participating surgeons at one referral center from 2006 to 2017. There were 11 men and eight women with a median age of 59 years (range 46 to 80 years). The minimum follow-up required for this series was 12 months; however, patients who reached an endpoint (death, radiographic loosening, or implant revision) before that time were included. One of these 19 patients was lost to follow-up but was not known to have died. The median follow-up was 24 months (range 0 to 116 months). Eight of the 19 patients presented with pathologic fractures. Ten of 19 lesions involved the femur, and nine of 19 were in the humerus. The most common pathologic finding was renal cell carcinoma (in 10 of 19). Survival estimates of the patients were calculated using the Kaplan-Meier method. A competing risks estimator was used to evaluate implant survival, using death of the patient as the competing risk. We also estimated the cumulative incidence of aseptic loosening in a competing risk analysis. Radiographs were analyzed for radiolucency at the bone-cement-implant interfaces, fracture, integrity of the cement mantle, and component position stability. Complications were assessed using record review that was performed by an individual who was not involved in the initial care of the patients. Functional outcomes were assessed using the MSTS93 scoring system. RESULTS: Patient survivorship was 68% (95% CI 50% to 93%) at 1 year, 53% (95% CI 34% to 81%) at 2 years, and 14% (95% CI 4% to 49%) at 5 years; the median patient survival time after reconstruction was 25 months (range 0 to 116 months). In the competing risk analysis, using death as the competing risk, the cumulative incidence of implant revision was 11% (95% CI 2% to 29%) at 1 year and 16% (95% CI 4% to 36%) at 5 years after surgery; however, the cumulative incidence of aseptic loosening (with death as a competing risk) was 22% (95% CI 6% to 43%) at 1 year and 33% (95% CI 13% to 55%) at 5 years after surgery. Other complications included one patient who died postoperatively of cardiac arrest, one patient with delayed wound healing, two patients with bone recurrence, and one patient who experienced local soft tissue recurrence that was excised without implant revision. Total MSTS93 scores improved from a mean of 12.6 ± 8.1 (42% ± 27%) preoperatively to 21.5 ± 5.0 (72% ± 17%) at 3 months postoperatively (p < 0.001) and 21.6 ± 8.5 (72% ± 28%) at 2 years postoperatively (p = 0.98; 3 months versus 2 years). CONCLUSION: Resection of diaphyseal metastases with intercalary reconstruction can provide stability and short-term improvement in function for patients with advanced metastatic disease and extensive cortical destruction. Aseptic loosening is a concern, particularly in the humerus; however, the competing risk analysis suggests the procedure is adequate for most patients, because many in this series died of disease without undergoing revision. LEVEL OF EVIDENCE: Level IV, therapeutic study .

Alignment and Fixation in Revision Total Knee Arthroplasty With Press-Fit, Offset, Diaphyseal-Engaging Stem Extensions, and Eccentric Reaming Technique.

BACKGROUND: A revision total knee arthroplasty must control limb alignment, often to address the cause of failure. Press-fit stems that engage the diaphysis with cement restricted to the metaphysis constitute one fixation technique. These long stems restrict coronal alignment of the prosthesis and as a result reduce the likelihood of extreme malposition. For the same reasons, long stems can make it difficult to manipulate alignment and achieve a specific coronal alignment angle. Nevertheless, femoral stems with a tight diaphyseal fit may still occupy a small range of varus-valgus positions due to the conical distal femoral metaphysis. Pulling the reamer toward the lateral endosteum increases femoral component coronal alignment toward a valgus direction and pushing the reamer medially increases alignment in a more varus direction. A straight stem, in combination with a medially directed reaming, would result in a femoral component that overhangs medially, but an offset stem can recenter the femoral component and maintain the desired alignment. We hypothesized that diaphyseal fit plus this reaming technique can control limb coronal alignment and provide fixation. METHODS: This was a retrospective clinical and long-leg radiographic study of consecutive revision total knee arthroplasties with minimum 2-year follow-up. Outcomes were correlated with New Zealand Joint Registry data to identify rerevisions of 111 consecutive revision knee arthroplasties, 92 after exclusions, at a minimum 2-year (range, 2 to 10) follow-up. RESULTS: Mean femoral and tibial canal fill exceeded 91% on antero-posterior and lateral radiographs. The mean hip-knee-ankle angle was 179.6o (174.9-184.0) with 80% within ± 3o of neutral. The hip-ankle axis crossed the central Kennedy zone in 76.5% of cases and the other 24.6% crossed the inner medial and inner lateral zones. Tibial components: 99.0% ± 3o. Femoral components: 89.5% within ± 3o. There were 5 knees that failed due to infection, 3 from femoral loosening, and 1 due to recurvatum instability from polio. CONCLUSIONS: This study describes a surgical plan and technique for achieving target coronal alignment with press-fit diaphyseal fixation. It is the only series of revision knee arthroplasties with diaphyseal press-fit stems to report canal fill in 2 planes and coronal alignment on full-length radiographs.

Precision shaping of elastic stable intramedullary nail for the treatment of metaphyseal diaphysis junction fracture of the distal radius in children: a preliminary report in two centers.

BACKGROUND: This study introduces a novel retrograde precision shaping elastic stable intramedullary nailing (ESIN-RPS) technique and reports clinical outcomes in pediatric distal radius metaphyseal diaphysis junction (DRMDJ) fracture. METHODS: Data about DRMDJs were collected from February 1, 2020, to April 31, 2022 at two hospitals, retrospectively. All patients were treated with closed reduction and ESIN-RPS fixation. The operation time, blood loss, fluoroscopy times, alignment, and residual angulation on X-ray were recorded. At the last follow-up, the function of wrist and forearm rotation were evaluated. RESULTS: Totally, 23 patients were recruited. The mean time of follow-up was 11 months and the minimum was 6 months. The mean operation time was 52 min, and the mean fluoroscopies pulses were 6 times. The postoperative anterioposterior (AP) alignment was 93 ± 4% and the lateral alignment was 95 ± 3%. The postoperative AP angulation was (4 ± 1)°, and the lateral angulation was (3 ± 1)°. At the last follow-up, the evaluation of the Gartland and Werley demerit criteria of wrist revealed 22 excellent cases and 1 good case. The forearm rotation and thumb dorsiflexion functions were not limited. CONCLUSION: The ESIN-RPS is a novel, safe, and effective method for the treatment of pediatric DRMDJ fracture.

Paediatric tibial shaft fractures: an instructional review for the FRCS exam.

This instructional review presents the literature and guidelines relevant to the classification, management and prognosis of paediatric tibial shaft fractures at a level appropriate for the FRCS exit examination in Trauma and Orthopaedic surgery.

Effect of Length Stability on Complications in the Treatment of Preadolescent Diaphyseal Femur Fractures Treated With Elastic Stable Intramedullary Nailing.

OBJECTIVES: To examine the effectiveness and complication rates in age- and size-appropriate patients with either stable or unstable fracture patterns treated with elastic stable intramedullary nailing (ESIN). DESIGN: Retrospective case series. SETTING: Academic tertiary care children's hospital. PATIENTS/PARTICIPANTS: This was a consecutive series of 106 preadolescent children with femoral shaft fractures. The mean age of the patients was 8.0 years (range, 4.0-16.0 years). INTERVENTION: All children were treated by retrograde ESIN. MAIN OUTCOME MEASURES: Fractures were categorized as either length stable or unstable. Length stability and complications were assessed. A subset of patients with final full-length, standing x-rays was also evaluated. RESULTS: We analyzed 63 stable and 43 length unstable fractures. The mean age and weight of the patients with stable and unstable fractures were similar. There was no difference in complication rates between groups (χ2(1) = 0.00, P = 0.99). There was no difference (t(96.93) = 0.53, P = 0.59) in femoral shaft length change. Leg length discrepancies as assessed by full-length standing radiographs at follow-up were similar (χ2(2) = 1.52, P = 0.47). CONCLUSIONS: Preadolescent children younger than 10 years do not experience increased complications after ESIN of length unstable femur fractures [odds ratio (OR) = 1.68 (0.18-16.87), P = 0.65]. Length unstable femur fractures are not at increased risk of more complications [OR = 0.90 (0.26-2.92), P = 0.87], early femoral shortening [OR = (0.42-2.02), P = 0.85], or leg length discrepancy [OR = (0.13-1.56), P = 0.21] when treated with ESIN. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for complete description of levels of evidence.

Hip reconstruction using a customized intercalary prosthesis with the rhino horn-designed uncemented stem for ultrashort proximal femur segments following tumor resection: a combined biomechanical and clinical study.

BACKGROUND: Hip-preserved reconstruction for patients with ultrashort proximal femur segments following extensive femoral diaphyseal tumor resection is a formidable undertaking. A customized intercalary prosthesis with a rhino horn-designed uncemented stem was developed for the reconstruction of these extensive skeletal defects. METHODS: This study was designed to analyze and compare the differences in the biomechanical behavior between the normal femur and the femur with diaphyseal defects reconstructed by an intercalary prosthesis with different stems. The biomechanical behavior under physiological loading conditions is analyzed using the healthy femur as the reference. Five three-dimensional finite element models (healthy, customized intercalary prosthesis with four different stems implemented, respectively) were developed, together with a clinical follow-up of 12 patients who underwent intercalary femoral replacement. RESULTS: The biomechanical results showed that normal-like stress and displacement distribution patterns were observed in the remaining proximal femur segments after reconstructions with the rhino horn-designed uncemented stems, compared with the straight stem. Stem A showed better biomechanical performance, whereas the fixation system with Stem B was relatively unstable. The clinical results were consistent with the FEA results. After a mean follow-up period of 32.33 ± 9.12 months, osteointegration and satisfactory clinical outcomes were observed in all patients. Aseptic loosening (asymptomatic) occurred in one patient reconstructed by Stem B; there were no other postoperative complications in the remaining 11 patients. CONCLUSION: The rhino horn-designed uncemented stem is outstanding in precise shape matching and osseointegration. This novel prosthesis design may be beneficial in decreasing the risk of mechanical failure and aseptic loosening, especially when Stem A is used. Therefore, the customized intercalary prosthesis with this rhino horn-designed uncemented stem might be a reasonable alternative for the reconstruction of SSPF following extensive tumor resection.

Functional and radiological outcomes of primary ring fixator versus antibiotic nail in open tibial diaphyseal fractures: A prospective study.

BACKGROUND: Management of open fractures of tibia is still a matter of debate due to high incidence of infections. Traditionally external fixators have been advocated in managing open tibial fractures. Due to limited efficacy of systemic antibiotics, recently antibiotic coated intramedullary interlocking nails have been developed for the management of open tibia fractures. Therefore, we conducted this prospective randomized study to compare the functional and radiological outcomes of primary ring fixator versus antibiotic coated nail in open diaphyseal tibial fractures. METHODS: The study included 32 patients with Gustilo-Anderson type II and type IIIA fractures of tibial diaphysis. Out of them 16 patients were managed with Ring External Fixator (Group I) and 16 were managed with OssiproÒ gentamicin intramedullary interlocking tibial nail (Group II). The radiological and functional outcomes were assessed at final follow-up according to and SMFA criteria. Statistical analysis of the data was performed using IBM SPSS statistics 2.0 software. Chi square test and independent student t-test were used and a P value <0.05 was considered statistically significant RESULTS: Union was achieved in 15 patients (93.8%) in group I and 13 patients (81.2%) in group II. Pin tract infection was seen in 6 patients (37.5%) in group I, whereas infection was present in 2 patients (12.5%) in group II. Bone results were excellent in 13 patients (81.3%), good in 2 patients (12.5%), poor in one patient (6.3%). In group II, bone results were excellent in 12 patients (75%), good in one patient (6.2%), poor in 3 patients (18.8%). At 1 year of final follow up, mean SMFA score was 24.41±5.87 in group I, whereas mean SMFA score was 23.703±8.02 in group II. CONCLUSION: Ring fixator as well as antibiotic coated tibial interlocking nail achieved comparable rates of union in the present study. Complication rates were similar in both the groups and the functional and radiological outcomes were comparable in both groups. Results of this study indicate that although ring fixation is an established option for management of open tibial fractures, antibiotic-coated intramedullary nail is also a reliable option in open Grade II and grade IIIA injuries. LEVEL OF EVIDENCE: Level II.

Feline Diaphyseal Fractures: Management and treatment options.

PRACTICAL RELEVANCE: Cats frequently present with diaphyseal fractures, which require treatment in order to achieve a good return to function. These fractures often occur due to significant trauma; for example, as a result of road traffic accidents, high-rise syndrome and dog bite wounds. The first priority is to ensure the patient is systemically well before embarking on any specific surgical treatment of a fracture. CLINICAL CHALLENGES: Surgical management of diaphyseal fractures can be challenging due to the surgical approach for some bones being technically demanding, for example because of the presence of important neurovascular structures, and the small size of feline bones, which limits the choice of implant size and strength. Further, it may be difficult to visualise fracture alignment when using minimally invasive techniques, although the use of intraoperative fluoroscopy can aid with this, and malalignment can be common for some fracture repairs, particularly in cases where anatomical reconstruction is not possible. AIMS: This review focuses on diaphyseal long bone fractures and aims to assist decision-making, with an overview of the management and treatment options available. EVIDENCE BASE: Many textbooks and original articles have been published on aspects of managing fractures in small animals. The authors also provide recommendations based upon their own clinical experience.

Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis.

To understand the potential and limitations of the different available surgical techniques used to treat large, long-bone diaphyseal defects by focusing on union, complication, re-intervention, and failure rates, summarizing the pros and cons of each technique. A literature search was performed on PubMed, Web of Science, and Cochrane databases up to March 16th, 2022; Inclusion criteria were clinical studies written in English, of any level of evidence, with more than five patients, describing the treatment of diaphyseal bone defects. The primary outcome was the analysis of results in terms of primary union, complication, reintervention, and failure rate of the four major groups of techniques: bone allograft and autograft, bone transport, vascularized and non-vascularized fibular graft, and endoprosthesis. The statistical analysis was carried out according to Neyeloff et al., and the Mantel-Haenszel method was used to provide pooled rates across the studies. The influence of the various techniques on union rates, complication rates, and reintervention rates was assessed by a z test on the pooled rates with their corresponding 95% CIs. Assessment of risk of bias and quality of evidence was based on Downs and Black's "Checklist for Measuring Quality" and Rob 2.0 tool. Certainty of yielded evidence was evaluated with the GRADE system. Seventy-four articles were included on 1781 patients treated for the reconstruction of diaphyseal bone defects, 1496 cases in the inferior limb, and 285 in the upper limb, with trauma being the main cause of bone defect. The meta-analysis identified different outcomes in terms of results and risks. Primary union, complications, and reinterventions were 75%, 26% and 23% for bone allografts and autografts, 91%, 62% and 19% for the bone transport group, and 78%, 38% and 23% for fibular grafts; mean time to union was between 7.8 and 8.9 months in all these groups. Results varied according to the different aetiologies, endoprosthesis was the best solution for tumour, although with a 22% failure rate, while trauma presented a more composite outcome, with fibular grafts providing a faster time to union (6.9 months), while cancellous and cortical-cancellous grafts caused less complications, reinterventions, and failures. The literature about this topic has overall limited quality. However, important conclusions can be made: Many options are available to treat critical-size defects of the diaphysis, but no one appears to be an optimal solution in terms of a safe, satisfactory, and long-lasting outcome. Regardless of the bone defect cause, bone transport techniques showed a better primary union rate, but bone allograft and autograft had fewer complication, reintervention, and failure rates than the other techniques. The specific lesion aetiology represents a critical aspect influencing potential and limitations and therefore the choice of the most suitable technique to address the challenging large diaphyseal defects.

Plate Fixation for Atypical Fractures of the Femoral Diaphysis.

Background: Plate fixation for atypical femoral fractures has shown high failure rates compared to intramedullary nail fixation. The aim of this study was to evaluate the radiological results of patients treated with a plate and screws for atypical fractures of the femoral diaphysis. Methods: This study was conducted retrospectively on 16 patients who had undergone internal fixation using plates for treatment of atypical femoral complete fractures from 2007 to 2015. Nine patients were treated with lag screws and short plates while 7 patients were treated with position screws and long plates, which covered the whole femur. Radiologic evaluation was performed on all patients. Complications were also evaluated. Results: Bone union was achieved in all patients and the average bone union time was 17.7 weeks (range, 14-28 weeks). There was no correlation between the preoperative use of a bisphosphonate, plate length, postoperative teriparatide use, and the time to bone union. Regarding complications, 2 cases of complete fractures and 1 impending fracture occurred at the end of short plates. Conclusions: Satisfactory results were obtained with use of plates for patients with atypical femoral complete diaphyseal fractures, in whom intramedullary nails could not be applied due to severe bowing. In particular, it seemed advantageous compared with intramedullary nail fixation in that it could maintain the leg length through anatomical reduction and prevent iatrogenic fracture.