Distal blocking screw augmentation in ulnar intramedullary nail fixation of adult forearm diaphyseal fractures.

PURPOSE: This study aimed to evaluate the effect of distal blocking screws on the stability and healing of ulnar diaphyseal fractures treated with intramedullary (IM) nails. The primary research question was whether the addition of distal blocking screws enhanced fracture stabilization and promoted faster healing than the standard IM nailing techniques. METHODS: This retrospective study reviewed medical records of 30 patients with ulnar diaphyseal fractures treated from February 2018 to September 2023. The patients were divided into two groups: those treated using IM nails alone (n = 17) and those treated with using IM nails with distal blocking screws (n = 13). The surgical time, medullary canal space, fracture healing time, and complications were assessed. Functional outcomes were evaluated using the Grace and Eversmann rating system, the DASH scores, and the VAS scores. RESULTS: The addition of distal blocking screws resulted in a slightly longer surgical time (56 min vs 47 min). However, the group with distal blocking screws had smaller medullary canal space and showed significantly faster fracture healing times (2.3 months vs 3.9 months; p = .036). There were no reported complications of nonunion, nerve injury, or infection in the distal blocking screw group, whereas the IM nail-only group had one case of nonunion (5.7%). CONCLUSION: The use of distal blocking screws in conjunction with IM nails for ulnar diaphyseal fractures improves fracture stability and promotes faster healing.

Single-centre results of a randomised controlled trial comparing the Gamma3 nail and a sliding hip screw to treat AO type 31-A1 and 31-A2 trochanteric fractures.

PURPOSE: The primary goal of this randomised controlled trial was to investigate whether there are differences in the outcome between the Gamma3 nail and a sliding hip screw (SHS) regarding quality of life 1 year after surgery. METHODS: In a controlled randomised trial, we compared the Gamma3 nail (Stryker) and a SHS (Omega, Stryker) in the treatment of 193 patients with pertrochanteric fractures. The follow-up period was 12 months. The outcomes included the surgical duration, health-related quality of life measured with the EQ-5D Index and a Visual Analogue Scale (VAS), the living situation and use of walking aid before trauma and 52 weeks after surgery; the Parker Mobility Score; the Harris Hip Score; and the revision, complication and mortality rates. RESULTS: The Gamma3 group had a significantly shorter surgical duration than the SHS group (p < 0.0001). Implant-related complications were significantly lower in the Gamma3 group (p > 0.05). The revision rate was significantly lower in the Gamma3 group based on intention-to-treat (p = 0.0336) as well as as-treated (p = 0.0302) analyses. Otherwise, we did not find significant difference between the two groups regarding the EQ-5D Index and VAS scores, the Parker Mobility Score, the Harris Hip Score, the mortality rate, the use of walking aids and the living situation. CONCLUSION: There were no detectable differences between the groups in terms of quality of life and clinical scores 12 months after surgery. The surgical duration and revision rate were superior for the Gamma3 group.

A clinical study on robot navigationassisted intramedullary nail treatment for humeral shaft fractures.

BACKGROUND: The purpose of this study was to evaluate the advantages of robot navigation system-assisted intramedullary nail treatment for humeral shaft fractures and compare it's efficacy with that of traditional surgical intramedullary nail treatment. MATERIALS AND METHODS: This was a retrospective analysis of patients with humeral shaft fractures who received intramedullary nail treatment at our centre from March 2020 to September 2022. The analysis was divided into a robot group and a traditional surgical group on the basis of whether the surgery involved a robot navigation system. We compared the baseline data (age, sex, cause of injury, fracture AO classification, and time of injury-induced surgery), intraoperative conditions (surgery time, length of main nail insertion incision, postoperative fluoroscopy frequency, intraoperative bleeding), fracture healing time, and shoulder joint function at 1 year postsurgery (ASES score and Constant-Murley score) between the two groups of patients. RESULTS: There was no statistically significant difference in the baseline data or average fracture healing time between the two groups of patients. However, the robotic group had significantly shorter surgical times, longer main nail incisions, fewer intraoperative fluoroscopies, and less intraoperative blood loss than did the traditional surgery group (P < 0.001). CONCLUSION: Robot navigation system-assisted intramedullary nail fixation for humeral shaft fractures is a reasonable and effective surgical plan. It can help surgeons determine the insertion point and proximal opening direction faster and more easily, shorten the surgical time, reduce bleeding, avoid more intraoperative fluoroscopy, and enable patients to achieve better shoulder functional outcomes.

Nonunion of the distal one-fourth of the tibia treated by retrograde tibial intramedullary nail.

OBJECTIVE: To evaluate the effectiveness of retrograde tibial intramedullary nail (RTN) in addressing nonunion in the distal one-fourth of the tibia. METHODS: This retrospective study included consecutive patients who were treated with RTN for nonunion in the distal one-fourth of the tibia between December 2020 and August 2023. Data regarding age, sex, injury mechanism, fracture type, initial fixation method, nonunion duration and type, risk factors, surgical duration, hospital stay, time to bone union, ankle function at final follow-up, and any complications were extracted from hospital records and analysed. RESULTS: Five patients in total were included, with previous treatments comprising locking plates and/or external fixation. The mean duration of RTN surgery was 94.0 ± 13.7 min, and mean duration of hospital stay was 9.8 ± 1.9 days. Patients were monitored for 10-18 months post RTN, achieving complete bone healing within a mean of 4.8 months. At the latest follow-up, the mean American Orthopedic Foot and Ankle Society (AOFAS) score was 84.4 ± 6.8 (range, 77-95). No complications, such as infection, reoperation, implant issues, rotational deformity, or shortening were reported. CONCLUSION: RTN emerges as a dependable, minimally invasive, and safe treatment modality for managing nonunion in the distal one-fourth of the tibia.

Comparison of treatment results of femoral shaft fracture with two methods of intramedullary nail (IMN) and plate.

BACKGROUND: Fracture of the femur is one of the most common fractures that, if not stabilized and treated properly, may lead to severe disability, impairment of the individual's efficiency, and numerous complications. This study aimed to evaluate the treatment results of femoral shaft fracture with two methods intramedullary nail (IMN) and Plate. MATERIALS AND METHODS: In this cross-sectional study, 60 patients with femoral bone fractures were admitted to Imam Khomeini Hospital in Jiroft in 2020 and were treated for at least one year after discharge. They were divided into two treatment groups - Plate fracture fixation (n = 30) and IMN fracture fixation (n = 30). Data were collected using a researcher-made checklist including patient demographics and treatment outcomes. The collected data were analyzed using SPSS-v 26 statistical software and descriptive and inferential statistical tests at a significance level of p < 0.05. RESULTS: Patients in the Plate treatment group were generally older (50-60 years) compared to the IMN treatment group (30-40 years), and there were more men than women in both groups. Only 10% of patients in each group developed superficial infections after surgery. There were more cases of deep infections in the Plate group, but it was not statistically significant. The IMN group had fewer cases of malignancy and claudication compared to the Plate group. Patients in the IMN group also returned to functional activities faster than those in the Plate group, which was a statistically significant difference. CONCLUSION: Considering that deep infection, non-union, malunion, claudication, and ability to return to functional activities in the group using nails treated was less than the group treated with plates, the treatment method of femoral fracture using IMN is the preferred treatment method.

Impact of operative position on rotational alignment after intramedullary nailing of trochanteric fractures: a comparative analysis of lateral decubitus versus supine position.

BACKGROUND: Fixation of trochanteric fractures with an intramedullary nail in a non-physiological position can cause poor functional outcomes. The aim of this study is to evaluate the effect of intraoperative patient position on rotational alignment in intramedullary nail fixation of trochanteric fractures. METHODS: The femoral rotational alignment of 84 trochanteric fracture patients who underwent intramedullary nailing was measured by computed tomography (CT) images. Patients were divided into two groups: the supine position on the fracture table (FT) (Group 1, n = 42) and the lateral decubitus (LD) position (Group 2, n = 42). Femoral malrotation angles were measured and divided into three subgroups: insignificant, significant, and excessive. The number of intraoperative fluoroscopy images, preparation time, surgery time, and anesthesia time in both groups were compared. RESULTS: The malrotation degrees of patients in Group 1 ranged from 17° external rotation (ER) to 57° internal rotation (IR), with a mean of 10° IR. Of the patients in Group 1, 27 were insignificant, 5 were significant, and 10 were in the excessive subgroup. The malrotation degrees of patients in Group 2 ranged from 33° ER to 47° IR, with a mean of 11° IR. Of the patients in Group 2, 21 were insignificant, 12 were significant, and 9 were in the excessive subgroup. There was no statistically significant relationship between patient position and malrotation angle. The number of intraoperative fluoroscopy images, preparation time, and anesthesia time were statistically lower in Group 2. There was no statistically significant difference between Group 1 and Group 2 in terms of surgery time. CONCLUSION: Intramedullary nailing in the LD position is a reliable and practical surgical method in the treatment of femoral trochanteric fractures since there is no need for the use of a FT, the surgeon is exposed to less radiation, there is no risk of complications related to the traction of the FT, and there is a shorter operation time.

Reconstruction of bone defects around the ankle with retrograde gentamicin-coated tibial intramedullary nail (ETN PROtect™) for tibiotalocalcaneal arthrodesis: a case series.

PURPOSE: The objective of this study was to describe the use of retrograde gentamicin-coated tibial intramedullary nail (ETN PROtect™) in patients with tibial defects who required a tibiotalocalcaneal arthrodesis (TTC). METHODS: Consecutive series case review of seven men treated with TTC using retrograde PROtect™ between January 2018 and December 2023. The main outcomes evaluated were fracture union, complications, and the health-related quality of life using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L). RESULTS: The mean age was 45.3 ± 8.0 years. Six patients had a clinical history of chronic osteomyelitis, and one case underwent TTC for congenital pseudoarthrosis. Fracture union was achieved in 5 of 7 patients between 4 and 11 months after surgery. Three patients developed complications; two patients had fistulas, and one had persistent pain. At the end of the follow-up, a median of 70 points (interquartile range: 60 to 90) on the EQ-5D-3L was reported. No complications directly attributed to the use of the PROtect™ were reported. CONCLUSION: TTC with retrograde PROtect™ is a prophylactic treatment option in patients with tibial defects treated with external fixation requiring a tibiotalar and subtalar arthrodesis. This novel use of PROtect™ allows simultaneous fixation of the tibiotalocalcaneal joint and protection of the regenerated bone, facilitating earlier rehabilitation in patients at high risk for postoperative infections.

Correction of a Golf Club Deformity of the Femur Using a Computer-Assisted Circular Ring Fixator: A Case Report.

CASE: The golf club deformity is the most notable malreduction that occurs after distal femur fracture fixation. This can lead to disruption of the patient's knee biomechanics, arthritis, and functional deterioration. There is a lack of consensus for optimal treatment of these malunions among the orthopaedic community. We present a technique that uses an osteotomy and ring external fixation with computer-assisted deformity correction and retrograde intramedullary nailing to secure correction. CONCLUSION: Our case shows a potential means to achieve a reliable and objective method of measuring, correcting, and securing the fixation of a golf club deformity.

Predictors for 1-year mortality in geriatric patients following fragile intertrochanteric fracture surgery.

OBJECTIVE: To investigate the risk factors influencing 1-year mortality after intramedullary nail fixation for fragile intertrochanteric fracture in elderly individuals. METHODS: The medical records of 622 consecutive elderly patients (aged ≥ 65 years) with fragile intertrochanteric fractures treated with proximal femoral nail anti-rotation (PFNA) and followed-up were retrospectively analyzed. The patients were divided into death and survival groups according to their survival status within 1 year after surgery, and the differences in age, sex, region of residence, tobacco use, alcohol use, body mass index (BMI), comorbidities (hypertension, diabetes mellitus, coronary heart disease, stroke, dementia, chronic obstructive pulmonary disease, pneumonia), preoperative hemoglobin, preoperative albumin, deep vein thrombosis, fracture type (AO classification), injury-to-surgery time, American Society of Anesthesiologists (ASA) score, anesthesia modality, duration of surgery, intraoperative blood loss, and blood transfusion were compared. The Kaplan-Meier method was used for univariate analysis to screen for statistically significant differences between the two groups, and the data were entered into the Cox proportional hazards model for multivariate analysis to determine independent risk factors affecting 1-year postoperative mortality. For subgroup analysis, we explored the varying effects of hypoproteinemia and being underweight in patients of different genders, as well as the effects of different age ranges, different injury-to-surgery times, and different blood transfusion volumes on 1-year postoperative mortality. RESULTS: The mortality rates at 1, 3, and 6 months, and 1 year after surgery were 3.9%, 7.2%, 10.1%, and 15.3%, respectively. Univariate analysis showed that advanced age, male sex, tobacco use, underweight (BMI < 18.5), coronary heart disease, stroke, dementia, pneumonia, number of comorbidities ≥ 3, hypoproteinemia and injury-to-surgery time ≤ 2 days were associated with the 1-year postoperative survival status (P < 0.1). Multivariate analysis revealed that advanced age, male sex, dementia, number of comorbidities ≥ 3, hypoalbuminemia, and being underweight were independent risk factors for 1-year postoperative mortality. Subgroup analysis showed that being underweight was associated with 1-year postoperative mortality only in male patients but not in female patients, whereas hypoproteinemia was associated with 1-year postoperative mortality in both male and female patients. Furthermore, an injury-to-surgery time of less than 2 days improved patient survival, and patients more than 80 years old showed an elevated risk of postoperative mortality. CONCLUSIONS: Preoperative health status is a critical predictor of postoperative outcomes in elderly patients with fragile intertrochanteric fractures. Priority care should be given to the patients who are elderly, male, have dementia, have comorbidities, or are malnourished. Prompt nutritional reinforcement should be provided to patients with intertrochanteric fractures with comorbid hypoproteinemia and underweight. Furthermore, surgery should be performed as early as possible in patients with fewer comorbidities.

Elastic stable intramedullary nailing in paediatric diaphyseal forearm fractures - a retrospective analysis of 201 cases.

BACKGROUND: Forearm shaft fractures are common injuries, often caused by falling from a fully-upright position or falling off a bike. They can be treated nonoperatively or surgically with intramedullary nailing or plates. The method of choice for treating pediatric forearm shaft fractures is the application of elastic stable intramedullary nailing (ESIN)|. The aim of the study was to evaluate ESIN in pediatric patients with forearm shaft fractures based on radiological images, and determine the etiology and complication rate associated with the injury. METHODS: The study included 201 patients, 30.5% female 69.5% male, aged 1 to 17 years (mean 9.1 years; SD = 3.2), all had been diagnosed with a fracture of the forearm shaft and had been treated surgically with ESIN. In addition, all possessed a complete set of X-ray images and had attended a minimum six-month follow-up examination of the forearm. Axial alignment was evaluated retrospectively in the anatomical (AP) and lateral (LAT) positions. In total, 402 radiographs were examined. Of the injuries, 68% occurred during sports activity and 75% involved both the radius and the ulna. RESULTS: Union was observed in all cases. Mean axial alignment values in AP and LAT X-ray or both the ulna and radius were satisfactory. Axial alignment values were not influenced significantly by age, type of surgery, type of fracture or etiology. Plaster cast application (9.8% of cases) significantly influenced radius axial alignment. The complication rate was 11.4% (n = 23). Significantly more complications were observed in patients receiving open reduction internal fixation (ORIF) (p = 0.0025). CONCLUSION: The ESIN technique is an effective treatment for forearm diaphyseal fractures in children, with good results regarding reduction and bone healing, indicated by x-ray.

Five states of reduction in OTA/AO A1.3 intertrochanteric fractures of the femur a biomechanical study.

OBJECTIVE: This study aims to analyze the differences in mechanical stability of OTA/AO 31A1.3 intertrochanteric fractures under various reduction conditions. METHODS: Twenty standard synbone artificial femur test bones were selected for the OTA/AO 31A1.3 intertrochanteric fracture model. The models were divided into five groups according to their reduction state: positive support, neutral support, negative support, varus fixation, and valgus fixation, with four specimens in each group. All models were fixed using PFNA intramedullary fixation and subjected to static axial compression tests. The subsidence displacement of the proximal femur under different loads and the axial stiffness of the model were measured to verify the mechanical stability of the OTA/AO 31A1.3 intertrochanteric fracture under different reduction conditions. RESULTS: After the static axial compression test, the proximal femoral subsidence displacement in the positive support and neutral support groups was lower than that in the negative support, valgus fixation, and varus fixation groups (p < 0.001). The axial stiffness of the model was highest in the positive support group. Significant differences in subsidence displacement and axial stiffness were found between the groups (p < 0.001). The positive support group demonstrated the best mechanical stability, while the varus fixation group showed the poorest performance. CONCLUSION: Positive support of the medial cortex can be regarded as the best reduction state for OTA/AO 31A1.3 intertrochanteric fractures, suggesting that this approach should be preferred during surgery to enhance mechanical stability and improve clinical outcomes. Conversely, varus fixation should be avoided due to its inferior stability.

Enoxaparin and Early Postoperative Tibial Nailing: Increased Nonunion Revision Rates.

OBJECTIVES: To determine the association between postoperative enoxaparin use and the risk of requiring surgery for nonunion in patients treated with intramedullary nailing for midshaft fractures of the tibia. DESIGN: Retrospective cohort analysis. SETTING: Data were sourced from the PearlDiver national database. PATIENT SELECTION CRITERIA: Patients were identified through the PearlDiver database by using Current Procedural Terminology and International Classification of Diseases (ICD-10) codes. Included patients had undergone intramedullary nailing for midshaft fractures of the tibia between 2015 and 2020 and subsequently underwent revision surgery due to nonunion. OUTCOME MEASURES AND COMPARISONS: The primary outcome measured in this study was the rate of nonunion following intramedullary nailing for the different types of tibial shaft fractures (closed, Type I/II open, Type III open). For each fracture subtype, the study compared nonunion rates between those who received enoxaparin in the postoperative period and those who did not receive enoxaparin at any time during the first 6 weeks postoperatively. Factors such as the timing and duration of enoxaparin therapy and demographic variables were also considered. RESULTS: The study included 16,986 patients, average age was 49.2 years (SD 17.3); 43.1% were female. Five hundred four patients required revision surgery for nonunion (3.4%). Among patients who did not receive enoxaparin, the nonunion rates were 1.6%, 3.9%, and 6.9% for closed, Type I/II open, and Type III open fractures, respectively. For patients who received enoxaparin within the first 2 weeks, the nonunion rates were 2.6%, 4.7%, and 7.9% for closed (RR = 1.67, P < 0.0001), Type I/II open (RR = 1.21, P < 0.0001), and Type III open (RR = 1.17, P = 0.355) fractures, respectively. Logistic regression confirmed enoxaparin was independently associated with nonunion (odds ratios [OR] = 1.75, P = 0.0013 for closed fractures; OR = 1.51, P = 0.034 for Type I/II open fractures). Tobacco use was also a contributing factor (OR = 2.43, P < 0.0001 for closed fractures; OR = 2.00, P < 0.0001 for Type I/II open fractures; OR = 2.04, P = 0.0008 for Type III open fractures). CONCLUSIONS: The postoperative use of enoxaparin was associated with an elevated risk of nonunion in patients treated with intramedullary nailing for fractures of the tibial shaft. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

[F-type forceps for assisted reduction in femoral shaft fractures surgery].

OBJECTIVE: To explore clinical efficacy of F-type forceps for assisted reduction in femoral shaft fracture reduction. METHODS: Forty-five patients with femoral shaft fracture treated with intramedullary nail and internal fixation from January 2019 to December 2021 were retrospectively analyzed and divided into two groups according to different reduction methods. In observation group, there were 21 patients, included 15 males and 6 females, aged from 27 to 92 years old with an average of (53.38±18.81) years old;9 patients on the left side, 12 patients on the right side;7 patients were type A, 8 patients were type B and 6 patients were type C according to AO fracture classification;the time from injury to operation ranged from 7 to 13 days with an average of (4.62±3.34) days;reduction was assisted by F-shaped forceps. In control group, there were 24 patients, including 17 males and 7 females, aged from 20 to 92 years old with an average of (51.96±20.43) years old;12 patients on the left side, 12 patients on the right side;11 patients were type A, 8 patients were type B and 5 patients were type C according to AO fracture classification;the time from injury to operation ranged from 2 to 13 days with an average of (6.29±3.04) days;traditional reset mode was adopted. Operative time, intraoperative blood loss, intraoperative fluoroscopy times, intraoperative open reduction ratio, clinical healing time of fracture, postoperative complications, hospital stay, hospital cost and Lysholm score of knee joint at 6 and 12 months after surgery were compared between two groups to evaluate clinical effect. RESULTS: All patients were followed up for 12 to 24 months with an average of (16.60±3.45) months. In observation group, operative time, intraoperative blood loss, intraoperative fluoroscopy times, open reduction cases, and clinical healing time of fractures were (58.19±7.93) min, (88.10±44.45) ml, (25.29±5.54) times, 0 case, (4.76±0.77) months, respectively;while in control group was (79.33±22.94) min, (222.92±144.45) ml, (47.46±26.25) times, 5 cases, (7.13±1.80) months, and the difference between two groups were statistically significant (P<0.05). There were no significant difference in postoperative complications, length of stay and hospitalization cost between two groups (P>0.05). At 6 months after surgery, Lysholm score of knee joint in observation group (88.62±4.48) was better than that in control group (79.21±8.91) (F=21.948, P=0.000). There were no significant difference in support use, pain and squat score between two groups (P>0.05). At 12 months after surgery, Lysholm scores of stair climbing and pain in observation group were (9.62±1.20) and (19.76±1.92), which were better than those in control group (7.83±2.04) and (21.88±2.88) (P<0.05). There were no significant difference in scores and total scores of other items between two groups (P>0.05). CONCLUSION: Compared with traditional reduction method, F-type forceps instrument could shorten operation time, reduce intraoperative blood loss, reduce intraoperative fluoroscopy times, accelerate clinical healing of fracture, and promote earlier functional recovery of knee joint.

Early Active Motion by Suzuki Pins and Rubber Traction After Intramedullary Reduction of an Impaction Fracture: A Case Report.

CASE: A 39-year-old man fell during a mountain hike and injured his left, nondominant ring finger, presenting with swelling, tenderness, and crepitus of the proximal interphalangeal joint. A computed tomography scan demonstrated a displaced intra-articular impaction fracture of the middle phalanx base. Surgery was performed with a combination of intramedullary reduction by K-wire and dynamic external fixation, using a Suzuki frame, to allow early active motion and prevent collapse of the reduced fragments. At 1-year follow-up, the clinical and radiological results were excellent. CONCLUSION: The impaction fracture of our patient was successfully treated with Suzuki pins and rubber after intramedullary reduction by K-wire.

[Standard radiographic images in cephalomedullary nailing fixation for intertrochanteric femoral fractures].

Objective: To review and summarize the projections of radiographic images during cephalomedullary nailing fixation for intertrochanteric femoral fractures, and to propose a set of three projections as standard requirement in immediate postoperative fluoroscopy. Methods: Papers on intertrochanteric femoral fractures treated with cephalomedullary nailing fixation that published in a three-year period of 2021-2023 in four leading English orthopedic trauma journals were searched in PubMed. The presented radiographic pictures were identified and scrutinized as whether they were in standard anteroposterior and/or lateral projections of the implanted nails. The nonstandard presence percentage was calculated. Combined with clinical experience, the standard anteroposterior and lateral perspective images of femoral neck, the current situation of radiographic imaging in the operation of cephalomedullary nails, the literature analysis of nonstandard images, the impact of limb rotation on image interpretation, and the characteristics of anteromedial 30° oblique perspective were summarized and analyzed. Results: The presence of nonstandard radiographic pictures is 32.1% in anteroposterior view and 69.2% in lateral view in leading orthopedic trauma journals. In cephalomedullary nailing fixation operation of intertrochanteric femoral fractures, it is reasonable to use the radiographic images of the implanted nails to represent the fractured head-neck, as the head-neck implant (lag screw or helical blade) is aimed to put into centrally in femoral head in lateral projection. Limb rotation or nonstandard projections produced distortion of images, which interfers the surgeons' judgement of fracture reduction quality and the measurement of implant position parameters in femoral head (such as neck-shaft angle and tip-apex distance), and finally lead to a meaningless comparison with the accurate normal value. The 30° anteromedial oblique view from the true lateral (set as 0°) is a tangential projection of the cortices at the anteromedial inferior corner, which gives a clear profile for the determination of cortical apposition status and mechanical support. It is essential to get firstly the true standard lateral fluoroscopy of the nail (shown as a line), then rotate the C-arm to 90° and 30° to get anteroposterior and anteromedial oblique views, and use these three immediate postoperative radiographies as the baseline for evaluation of operative quality and follow-up comparisons. Conclusion: As for real-time monitoring of surgical steps, intraoperative fluoroscopy follows the "Enough is Good" principle, but as for immediate postoperative data storage and basis for operative quality evaluation and baseline for follow-up comparison, it is recommended to obtain a set of three standard radiographic pictures in anteroposterior, true lateral, and 30° anteromedial oblique fluoroscopic projections.

Different surgical interventions for unstable intertrochanteric fracture of the femur: Network meta-analysis.

OBJECTIVE: Although a large body of evidence has reported on surgical approaches for the treatment of unstable intertrochanteric femoral fractures, studies that comprehensively evaluate treatment outcomes are limited. The purpose of this study was to compare the effectiveness of extramedullary fixation (i.e., dynamic hip screw [DHS]), intramedullary fixation (i.e., the proximal femoral nailing [PFN]), and hemiarthroplasty (HA) for the treatment of unstable intertrochanteric femoral fractures using network meta-analysis. METHODS: This study meets the preferred reporting items for systematic reviews and meta-analyses criteria. The Patient, Intervention, Comparison and Outcome search protocol framework was used to search the Google Scholar, PubMed, Embase, and Cochrane Library databases were searched from inception until June 2023. RESULTS: A total of 15 randomized controlled trials, including 1282 patients were analyzed. The Harris hip score (HHS) after DHS fixation was the lowest compared with that of PFN fixation and HA. DHS fixation had a significantly longer operation time than that of PFN fixation. Compared with HA, a lower incidence of superficial wound infection was observed with PFN and DHS fixations. PFN was significantly more likely to be implant cut out compared with HA. Compared with DHS, PFN and HA showed a lower incidence of fracture healing malunion. CONCLUSION: HA and PFN have good efficacy in improving the HHS and preventing joint deformities. However, HA showed a higher incidence of superficial infection than that observed with PFN, whereas a higher risk of screw cutout is observed with PFN than with HA.

A Scoring System for Predicting Nonunion After Intramedullary Nailing of Femoral Shaft Fractures.

INTRODUCTION: Femoral shaft nonunion negatively affects patient quality of life. Although multiple risk factors have been identified for femoral shaft nonunion after intramedullary nail (IMN) fixation, there is no quantitative model for predicting nonunion. STUDY DESCRIPTION: The study is a retrospective cohort study of patients with femoral shaft fractures treated at two level one trauma centers who were followed to fracture union or nonunion. Patient, injury, and surgical characteristics were analyzed to create a quantitative model for nonunion risk after intramedullary nailing. METHODS: Eight hundred one patients aged 18 years and older with femoral shaft fractures treated with reamed, locked IMNs were identified. Risk factors including demographics, comorbidities, surgical variables, and injury-related characteristics were evaluated. Multivariate analysis was conducted, and several variables were included in a scoring system to predict nonunion risk. RESULTS: The overall nonunion rate was 7.62% (61/801). Multivariate analysis showed significant association among pulmonary injury (odds ratio [OR] = 2.19, P = 0.022), open fracture (OR=2.36, P = 0.02), current smoking (OR=3.05, P < 0.001), postoperative infection (OR=12.1, P = 0.007), AO/OTA fracture pattern type A or B (OR=0.43, P = 0.014), and percent cortical contact obtained intraoperatively ≥25% (OR=0.41, P = 0.021) and nonunion. The scoring system created to quantitatively stratify nonunion risk showed that a score of 3 or more yielded an OR of 6.38 for nonunion (c-statistic = 0.693, P < 0.0001). CONCLUSIONS: Femoral shaft nonunion risk is quantifiable based on several independent injury, patient, and surgical factors. This scoring system is an additional tool for clinical decision making when caring for patients with femoral shaft fractures treated with IMNs.

Biomechanical characteristic differences of two new types of intramedullary nail devices in the treatment of comminuted intertrochanteric fractures of femur: a comparative study based on finite element analysis.

OBJECTIVE: Given the recent application of two new types of intramedullary nail devices in the treatment of comminuted femoral intertrochanteric fractures (CFIFs), there is still a lack of deep understanding and comparative evaluation of their biomechanical properties. Therefore, this study aims to systematically compare the advantages and disadvantages of these two new devices with traditional proximal femoral nail antirotation (PFNA) and InterTan nails in the fixation of CFIFs through finite element analysis. METHODS: Based on the validated finite element model, this study constructed an accurate CFIFs model. In this model, PFNA, InterTan nails, proximal femoral bionic nails (PFBN), and new intramedullary systems (NIS) were implanted, totaling four groups of finite element models. Each group of models was subjected to simulation tests under a vertical load of 2100 N to evaluate the displacement and Von Mises stress (VMS) distribution of the femur and intramedullary nail devices. RESULTS: Under a vertical load of 2100 N, a comparative analysis of the four finite element models showed that the NIS device exhibited the most superior performance in terms of peak displacement, while the PFNA device performed relatively poorly. Although the NIS device had the highest peak stress in the femur, it had the smallest peak displacement of both the femur and intramedullary nail devices, and the peak stress was mainly concentrated on the lateral side of the femur, with significantly lower stress in the proximal femur compared to the other three intramedullary nail devices. In contrast, the PFBN device had the lowest peak stress in the femur, and its peak displacement of both the femur and intramedullary nail devices was also less than that of PFNA and InterTan nails. CONCLUSION: This study demonstrates that in the treatment of CFIFs, PFBN and NIS devices exhibit superior biomechanical performance compared to traditional PFNA and InterTan nail devices. Especially the NIS device, which can achieve good biomechanical results when fixing femoral intertrochanteric fractures with missing medial wall. Therefore, both PFBN and NIS devices can be considered reliable closed reduction and internal fixation techniques for the treatment of CFIFs, with potential clinical application value.

The fibular intramedullary nail versus plate fixation for ankle fractures in adults: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: The effectiveness and safety of fibular intramedullary nail fixation (FINF) compared to plate fixation (PF) in treating ankle fractures among adults remains unclear. Therefore, we conducted a meta-analysis to assess the efficacy and safety of FINF versus PF, aiming to provide orthopedic surgeons with valuable insights when choosing between the two internal fixation methods for patient treatment. METHODS: PubMed, EMBASE, and SCOPUS were systematically searched for articles comparing FINF and PF in ankle fractures among adults. Functional outcomes, complications, and bony union were compared between the implants. RESULTS: A total of seven studies were included in the study, involving 586 patients. The results revealed no statistically significant differences in functional outcomes between two groups at 3, 6, and 12 months postoperatively. The outcomes favoring FINF comprised a lower infection rate (RR = 0.23, 95%CI, 0.11 to 0.47, P < 0.0001). Conversely, the PF group exhibited a superior performance in terms of hardware failure rate (RR = 2.05, 95%CI, 1.16 to 3.60, P = 0.01). A statistically significant difference was observed in the results of hardware failure rate in the subgroup of studies conducted in Europe (RR = 2.74, 95%CI, 1.45 to 5.18, P = 0.002). Comparable findings were also noted in a subgroup of older adults (RR = 4.25, 95%CI, 1.57 to 11.50, P = 0.004). CONCLUSION: This systematic review suggests that FINF exhibits comparable effectiveness in the management of ankle fractures among adults, as compared to PF. Consequently, it is imperative to further delineate the surgical indications for both FINF and PF with precision to mitigate the risk of complications. Nevertheless, larger sample sizes and multi-center RCTs are imperative to corroborate this conclusion in the future.

Intramedullary nailing at different distal tibial fracture levels: A biomechanical study.

BACKGROUND: Distal tibial fractures remains a significant challenge in orthopedic trauma surgery. As the fracture level approaches the joint, alternative fixation options instead of intramedullary nailing (IMN) come to the fore. The present study aimed to assess the biomechanical stability of IMN at different distal tibial fracture levels and the number of locking screws required. METHODS: Using a total of 21 sawbone models, 3 different tibial fracture levels (3, 4.5, and 6 cm proximally to the talocrural joint) were created and the fractures were fixed using 2, 3, or 4 distal locking screws. A single compression force at a speed of 30 mm/min with a maximum force of 800 Newton and a cyclic compression force of 60 cycles at a speed of 60 mm/min was applied to all tibia models. The applied weight and displacements from the fracture lines were recorded and evaluated. RESULTS: There was no statistically significant difference in fixation with 2 distal locking screws in groups 1, 2, and 3 (single test P =.9689) (cyclic test P =.8050). Therefore, if 2 distal screws are used, the fracture level does not affect the strength of fixation. In fractures located 6 cm proximal to the talocrural joint, all 4 holes of the nail can be used to insert screws, which provides a stronger fixation. When 2 screws are used, a statistically weaker fixation is obtained than with 3 or 4 screws. However, there is no significant difference between using 3 or 4 screws. CONCLUSION: Our findings support the use of IMN with 2 distal locking screws as a viable option for the management of distal tibial fractures. We found that it provides sufficient fixation regardless of the fracture level, suggesting that there is no need to choose an alternative fixation technique due to concerns of inadequate fixation as the fracture line moves distally. In cases where more stable fixation is desired, an additional locking screw can be used, but the potential increase in procedure and fluoroscopy time should be considered.