Does the distal nail position impact the rates of misalignment and bone union in distal tibial fractures?

PURPOSE: This retrospective study aimed to assess the impact of distal nail placement on misalignment and healing rates in distal tibial fractures. METHODS: We reviewed all patients with distal tibial fracture treated with intramedullary nailing between 2015 and 2021, and a minimum follow-up of 12 months. Distal nail positioning was determined according to the Triantafillou zones. We related these positioning zones to misalignments (alignment ≥ 3°) and too bony union disorders (delayed union, non-union). RESULTS: Out of the 62 patients included, 56 (90.3%) show bone union without additional procedure, 3 (4.8%) with dynamization, and 3 (4.8%) showed non-union. Twenty-one (33.8%) presented misalignment, with valgus in the coronal plane being the most frequent (76.19%). In patients with and without misalignment, the most frequent distal nail position was 2-2 in 47.6% and 80.5%, respectively (p = 0.01). In multivariate analysis, distal nail positioning in the 2-2 zone showed a significant protective effect against misalignment (OR 0.18; p = 0.018), while nail positioning in the 3-2 zone generated a significant risk of misalignment (OR 18.55; p = 0.009). CONCLUSION: In intramedullary nailing of distal tibial fractures, distal positioning of the nail slightly lateral to the center of the talus in the coronal plane and slightly posterior in the sagittal plane (zone 2-2) allows high alignment percentages to be obtained. Positioning medial to this point in the coronal plane (zone 3) is associated with more significant misalignment and should be avoided.

Antibiotic cement-coated rigid locked nails in infected femoral and tibial nonunion. Reoperation rates of commercial versus custom-made nails.

INTRODUCTION: The objective of this study is to assess bone union, infection control, and reoperation rates in a series of patients with infected femoral or tibial nonunion treated with antibiotic-cement-coated rigid nails and to compare the results obtained with custom-made nails versus commercial nails. METHODS: We retrospectively analyzed a series of consecutive patients with infected nonunion of the femur or the tibia treated with antibiotic-cement-coated rigid nails between January 2010 and 2020. We assessed patients' distinctive characteristics, initial injury, type of nail used (custom-made nail with vancomycin or commercial nail with gentamicin), success rate (bone union + infection control), reoperation rate, and failure rate. Comparative analyses were conducted between reoperated and non-reoperated patients regarding the type of nail used. A multivariate regression analysis was performed to assess the risk variables that impacted reoperation rates. RESULTS: We included 54 patients with 22 (40.74%) infected femoral nonunions and 32 (59.25%) tibial nonunions, who were treated with 38 (70.37%) custom-made antibiotic-cement coated nails and 16 (29.62%) commercial nails. Bone union and infection control were achieved in 51 (94.44%) cases. The reoperation rate was 40.74% (n = 22), and the failure rate was 5.55% (n = 3). The use of custom-made nails was associated with a higher risk of reoperation (Odds Ratio 4.71; 95% Confidence Interval 1.10 - 20.17; p = 0.036). CONCLUSION: Antibiotic-cement-coated nails reached a 94.44% success rate. Nails manufactured in the OR coated with vancomycin cement were associated with a higher risk of reoperation than commercial nails loaded with gentamicin cement. LEVEL OF EVIDENCE: III comparative, observational, non-randomized.

Effectiveness of Nail Dynamization in Delayed Union of Tibial Shaft Fractures: Relationship Between Fracture Morphology, Callus Diameter, and Union Rates.

OBJECTIVE: Dynamization has already been described as a secondary intervention for delay unions of tibial shaft fractures treated with intramedullary nailing. Although it's a common procedure, it is not widely supported in the literature. The purpose of this study was to determine the union rate of nail dynamization in cases of delayed union of diaphyseal tibial fractures, and assess the effect of fracture morphology on union rates. MATERIALS AND METHODS: We retrospectively analyzed a series of 199 consecutive tibial shaft fractures. We recorded the dynamization rate, period from nailing to dynamization, nailing to the union, the fracture pattern (according to AO/ASIF and whether it was closed or open), the callus diameter before dynamization (fracture healing index; FHI) and union/failure rates. RESULTS: Out of a total of 199 fractures treated during the study period, 41 (20.6%) were dynamized. After applying inclusion and exclusion criteria, 39 patients with 39 fractures were included in the study. The mean time from nailing to dynamization was 18.4 ± 7.2 weeks. The union rate was 92.3% (n = 36) over a mean time of 14.1 ± 5.6 weeks as from dynamization. The overall failure rate was 6.7% (n = 3). There was no significant association between failure and AO/ASIF classification (p > 0.05) or fracture exposure (X 2 = 0.19; p = 0.66). The pre-dynamization FHI of ≥ 1.17 was significantly associated with consolidation (p < 0.05). CONCLUSION: In cases of delayed union of tibial fractures, dynamization offered a high union rate associated with pre-dynamization FHI, while fracture morphology did not affect the failure rate.

Extended trochanteric osteotomy (ETO) and fluted tapered modular stems in revision hip arthroplasty. Does ETO integrity or consolidation, really matter?

INTRODUCTION: The objective of this study was to assess if the fracture and/or non-union of extended trochanteric osteotomy (ETO) affected the behavior and survival of modular fluted and tapered distal fixation stems in revision total hip arthroplasties (rTHA). METHODS: We retrospectively analyzed 52 rTHA in 52 patients. Preoperative diagnoses were mechanical loosening (42 cases), septic loosening (8), periprosthetic fracture (1), and femoral stem fracture (1). According to the Paprosky classification, femoral bone stock deficiencies were 19 type-II, 26 type IIIA, and 7 type IIIB. We assessed the behavior of the osteotomy (union, fracture, migration) and the survival and behavior (integration and subsidence) of prosthetic femoral stems. RESULTS: ETO union and non-union rates were 84.61% (44 patients) and 15.38% (8 cases) respectively. There were twelve (23%) intra-operative fractures of the osteotomy fragment and 11 (21.15%) migrations (4.5 mm on average). We observed bone union in 39 (75%) stems and 13 (25%) stable fibrous unions. Nine (17.3%) stems subsided 7 mm (2-15 mm) on average before becoming stable. Stem subsidence and integration was not significantly affected by ETO fracture/no fracture or union/non-union. The postoperative Harris Hip Score (HHS) improved significantly as compared to the pre-operative HHS (38.41 ± 3.54 vs 85.29 ± 3.36; p < 0.01). Patients were followed up for 55 (24-100) months. The overall implant survival at the end of follow-up was 100%. CONCLUSIONS: In this series, neither the non-union nor the intra-operative fracture of the ETO segment affected the behavior or medium-term survival of femoral stems.