ABSTRACT
BACKGROUND: Nonunion of femoral shaft fractures in children is rare, and there is no clear treatment protocol. In this case report, a pediatric femoral shaft fracture that developed in nonunion due to vitamin deficiency after osteosynthesis, which was successfully treated with vitamin augmentation and replacement with a rigid antegrade intramedullary nail, is described. CASE PRESENTATION: The patient is an 11-year-old Japanese girl. She injured her right femoral shaft fracture when she hit a wall after kickboarding down a hill and underwent osteosynthesis with a titanium elastic nail. Six months postoperatively, she developed nonunion, was found to be deficient in vitamins D and K, and was started on vitamin supplementation. She underwent replacement with a rigid antegrade intramedullary nail at 7 months postoperatively, and bone union was achieved 3 months after reoperation. CONCLUSION: When delayed union of a fracture is observed postoperatively, even in children without underlying disease, the cause of the problem must be investigated and treated promptly.
Subject(s)
Femoral Fractures , Fracture Fixation, Intramedullary , Hypokalemia , Female , Humans , Child , Reoperation/methods , Vitamin D/therapeutic use , Fracture Fixation, Intramedullary/methods , Bone Nails , Fracture Healing , Femoral Fractures/diagnostic imaging , Femoral Fractures/surgery , Vitamins , Treatment Outcome , Retrospective StudiesABSTRACT
Objective: The state of nutrition of senior patients with intertrochanteric fracture of femur before operation affects the patients' tolerance to the operation,the body recovery, healing of the wound and clinical prognosis. For these patients, the poor state of nutrition may lengthen the time of being in hospital, leading to poor hip recovery and clinical outcome. But currently, the relationship between functional recovery of hip joint after operation of intertrochanteric fracture in elderly patients and camp condition has not been reported. To investigate the effect of preoperative nutritional status on postoperative recovery of hip joint function in elderly patients with intertrochanteric fractures. Methods: Retrospective analysis was performed on the data of 96 elderly patients with intertrochanteric fracture of the femur treated with closed reduction PFNAfrom January 2021 to January 2022 in Dongying People's Hospital Trauma Orthopedics Department. There were 36 male patients and 60 female patients aged from 65 to 92.The patients were divided into the normal nutrition group (GNRI ≥ 92, n = 46) and the malnutrition group (GNRI < 92, n = 50). The general clinical data, time from injury to operation, intraoperative and postoperative allogeneic blood transfusion rate, postoperative complication rate, postoperative mortality 1 year, and Harris hip function score at 3, 6, 9 months and the last follow-up were compared between the two groups. Results: All patients were followed up for 9 to 15 months(mean,13.9 months) after surgery. The preoperative hemoglobin levels in the normal and malnutrition groups were 8.6-13.2 and 7.4-11.2 g/dL, respectively (P < .05). The time from injury to surgery in the normal nutrition group was significantly shorter than that in the malnutrition group (P < .01). The preoperative hemoglobin level in the normal nutrition group was significantly higher than that in the malnutrition group. The time from injury to operation in normal nutrition group and malnutrition group are respectively (1.1-5.2), (4.3-6.6)d; the intraoperative and postoperative allogeneic blood transfusion rates are respectively 47.8%(22/46), 92%(46/50);the incidence of postoperative complications are respectively 6.52%(3/46), 32%(16/50); the mortality rates within 1 year after operation are respectively 2.17%(1/46), 12%(6/50). In contrast, the postoperative allogeneic blood transfusion, postoperative complication, and postoperative complication rates in the normal nutrition group were significantly lower than those in the malnutrition group (P < .05). 3 months after surgery, the Harris hip function scores of patients in normal nutrition group and malnutrition group are respectively (75.26±4.02), (64.28±3.82); 6 months after surgery, the Harris hip function scores of them are respectively (80.42±3.86), (70.14±5.06).During the last follow-up, scores are (82.23±2.98), (72.12±4.62). At the 3, 6, and last follow-up after surgery, the Harris hip function score in the normal nutrition group was significantly higher than in the malnutrition group (P < .05). Conclusion: Preoperative malnutrition in elderly patients with intertrochanteric fracture has adverse effects on postoperative hip function recovery, and 1-year postoperative survival rate.GNRI can be used for simple screening. Early assessment of patients' nutritional status.
Subject(s)
Fracture Fixation, Intramedullary , Hip Fractures , Malnutrition , Humans , Male , Female , Aged , Retrospective Studies , Nutritional Status , Recovery of Function , Treatment Outcome , Bone Nails , Hip Fractures/surgery , Postoperative Complications/epidemiology , Hip Joint/surgery , HemoglobinsABSTRACT
Objective: Failure of bone healing after intramedullary nailing (IMN) of a femoral diaphyseal fracture is an uncommon condition, which can cause obvious pain symptoms and seriously affect the daily life of patients. Ununion of femoral fracture requires treatment to promote successful bone union. Augmentative plating (AP) has yielded good results in treating femoral nonunion after IMN. However, there are few large cohort studies and no technical standard for this treatment. To determine (1) the proportion of individuals with femoral nonunion after IMN who achieved radiographic signs of osseous union following the additional treatment of AP and autogenous bone grafting and (2) the factors associated with the failure of this treatment. Methods: Nonunion after IMN fixation is defined as an unhealed fracture with no radiographic signs of osseous union at least six months after IMN treatment. Osseous union as bridging bone on three of four cortices with the absence of a radiolucent line. Between January 2011 and January 2022, 83 individuals diagnosed with femoral nonunion after IMN fixation underwent AP and an autogenous bone graft. Results: Seventy-six of the 83 nonunion individuals attained osseous union by 12 months. Six of 36 (16.7%) subjects with mono-cortical plates had non-union. Conversely, one of 47 subjects (2%) with bi-cortical plates had non-union. There were 18 individuals whose AP had ≤6 cortices. Five of these 18 (38.5%) individuals had non-union. Two of 65 with an AP of >6 cortices had non-union. AP with ≤ 6 cortices was a major risk factor for the likelihood of unsuccessful procedures compared to AP with > 6 cortices. Three individuals experienced incision infection at the bone graft harvest site and were treated with local wound care. Conclusions: A high proportion of individuals with femoral nonunion after IMN fixation were salvaged by AP and an autogenous bone graft. Bi-cortical plate and screw intersection of more than six cortices may increase the treatment effectiveness. Limitations: There were limitations of this study. First, it was a retrospective study over a 10-year period, and the patients were treated by different orthopedic surgeons. Second, lack of functional evaluation is another limitation of the present work. Generalizability: The technique of bi-cortical plate and screw intersection of more than six cortices is not difficult for experienced orthopedic surgeons, and no special surgical tools is required. Closing Statement: Many literature has confirmed the good effect of APP technology in treating femoral nonunion after intramedullary nail fixation, but there are still cases of failure. Our study may enable this technology to achieve better therapeutic effects.
Subject(s)
Femoral Fractures , Fracture Fixation, Intramedullary , Fractures, Ununited , Humans , Retrospective Studies , Bone Nails , Bone Plates , Fractures, Ununited/diagnostic imaging , Fractures, Ununited/surgery , Fracture Fixation, Intramedullary/methods , Treatment Outcome , Femoral Fractures/diagnostic imaging , Femoral Fractures/surgeryABSTRACT
Objective: To explore the application value and safety of elastic stable intramedullary nailing (ESIN) in pediatric femoral fractures (FFs), providing more reliable safety for the treatment of FFs in the future. Methods: This study selected 60 cases of pediatric FFs who completed fracture treatment in our hospital between March 2014 and January 2023, with 32 cases undergoing ESIN fixation included in the research group (RG) and another 28 cases receiving plate internal fixation assigned to the control group (CG). The operative time (OT), intraoperative blood loss (IBL), incision length, fracture healing time, fixator removal time, weight-bearing time, and hospital length of stay (HLOS) of the two groups were counted, and the pain of the children was evaluated by the Visual Analogue Scale (VAS). The clinical efficacy and complication rate were recorded, and the hip and knee functions before and after treatment were evaluated by the Hospital for Special Surgery (HSS) score. After the completion of treatment, the child's family was surveyed about their satisfaction with the treatment. Results: The research group had less OT, IBL, and incision length, as well as shorter fracture healing time, fixator removal time, weight-bearing time, and HLOS than the control group (P < .05), with markedly lower VAS scores at 12h-48h postoperatively (P < .05). In addition, the research group demonstrated an obviously higher overall response rate (96.88%) and a lower complication rate (15.63%) than the control group (P < .05). Furthermore, HSS scores and treatment satisfaction were higher in the research group than in the control group (P < .05). Conclusions: ESIN is a highly effective treatment for pediatric femoral fractures, leading to accelerated fracture healing, improved mobility, and exhibiting high clinical application value.
Subject(s)
Femoral Fractures , Fracture Fixation, Intramedullary , Child , Humans , Fracture Healing/physiology , Bone Nails , Femoral Fractures/surgery , Fracture Fixation, Internal , Treatment Outcome , Retrospective StudiesABSTRACT
Objective: This study aims to evaluate the outcomes of senile femoral intertrochanteric fractures treated with proximal femoral nail anti-rotation (PFNA) internal fixation to those treated with prosthetic femoral head replacement. Methods: A total of 100 elderly patients suffering from femoral intertrochanteric fracture were selected for the study. They were divided into two groups (n = 50 in each group) based on fracture condition and preferred treatment. We compared perioperative indexes, complications, Soluble cell adhesion molecules-1 (sICAM-1), and TGF-1 levels, and assessed hip function using the Harris hip score (Harris) at 3, 6, and 12 months after surgery in two groups of patients. Results: Although the study group had shorter operating times and less intraoperative bleeding than the control group (P < .05), they had longer hospital stays and required more time before returning to full weight-bearing after surgery (P < .05). Neither group had a higher or lower rate of problems than the other (P > .05). Patients' sICAM-1 and TGF-1 levels were not significantly different from one another before surgery (P > .05), but after surgery, the sICAM-1 level in the control group was lower than that in the study group, and the TGF-1 level was higher than that in the study group (P < .05). Conclusion: PFNA internal fixation treatment offers the advantages of short operation time and low intraoperative bleeding, ensuring surgical safety. However, it requires a longer bed rest time post-operation and extended full weight-bearing time, although long-term hip recovery is preferable.
Subject(s)
Femoral Fractures , Fracture Fixation, Intramedullary , Hip Fractures , Humans , Aged , Femur Head , Bone Nails , Treatment Outcome , Retrospective Studies , Femoral Fractures/surgery , Hip Fractures/surgeryABSTRACT
Objective: To compare and analyze the effects of proximal femoral nail anti-rotation (PFNA) and femoral head replacement in treating elderly patients with femoral intertrochanteric fracture. Methods: A retrospective analysis was performed on clinical data of elderly patients with femoral intertrochanteric fractures from February 2019 to February 2021 in the hospital. Patients were divided into a control group (PFNA) and a study group (femoral head replacement) based on surgical methods after propensity score matching. Perioperative indicators, hematocrit (HCT), hemoglobin (Hb), hip function, and complications one year after surgery were compared between the two groups after excluding confounding factors. Result: Both groups had complete follow-ups without any cases lost. The study group had longer surgical time, higher intraoperative blood loss, and greater postoperative drainage volume compared to the control group, while the hospital stay and weight-bearing starting time were shorter in the study group (P < .05). There were statistically significant differences in HCT and Hb after surgery between the two groups (P < .05). One year after surgery, the excellent and good rate of hip function was 90.28% in the study group and 76.39% in the control group (P < .05). The total incidence rate of postoperative early complications was higher in the study group, while the total incidence rate of late postoperative complications was lower in the study group compared to the control group (P < .05). Conclusion: PFNA and femoral head replacement have their respective advantages in treating elderly patients with femoral intertrochanteric fractures. PFNA causes less trauma to patients but has poorer postoperative hip function recovery, while femoral head replacement causes greater trauma to patients but has better postoperative hip function recovery. Therefore, the appropriate surgical method can be selected based on the patient's specific conditions.
Subject(s)
Femoral Fractures , Fracture Fixation, Intramedullary , Hip Fractures , Humans , Aged , Retrospective Studies , Femur Head , Bone Nails , Fracture Fixation, Intramedullary/methods , Treatment Outcome , Hip Fractures/surgery , Femoral Fractures/surgery , Postoperative Complications/epidemiologyABSTRACT
INTRODUCTION: Proximal femur fractures have high rates of morbidity, mortality, and perioperative complications. Limiting anesthesia, especially in the elderly population, is a priority from a medical perspective. The goal of the current study is to present a technique of using local anesthetic with monitored anesthesia care (MAC) for the fixation of intertrochanteric (IT) femur fractures with cephalomedullary nailing (CMN), provide early clinical results in a small series of patients, and evaluate the safety, efficiency, and anesthetic efficacy of our technique. HYPOTHESIS: The use of only local anesthetic with MAC for the fixation of IT fractures is safe and leads to decreased operative times when compared to spinal and general anesthesia. MATERIALS AND METHODS: Patients undergoing cephalomedullary nailing (CMN) with a long nail for IT femur fractures by a single surgeon from January 2020 to June 2021 were identified retrospectively from a prospectively-collected patient registry. Patient demographics, operative time, length of hospital stay, perioperative medication use, and complications were collected. Analysis of variance, Chi2, linear regression, and two-sampled T-tests were performed to analyze potential differences between the local anesthesia group and the general or spinal anesthesia group. RESULTS: Thirty-seven patients were identified. Eleven patients underwent CMN using local anesthesia with MAC, 11 using spinal anesthesia, and 15 using general anesthesia. The local anesthesia group demonstrated significantly lower operating room times and anesthesia induction to incision time compared to other anesthesia techniques. The local anesthesia group also trended towards less need for vasopressors during surgery and less postoperative delirium. No differences were identified in intraoperative narcotic use, complications, patient mortality, or hospital readmissions. CONCLUSIONS: Local anesthesia with MAC for the treatment of IT fractures with CMN was associated with decreased operating room times and had similar complication rates including blood transfusions, readmissions, and mortalities, when compared to spinal and general anesthesia. LEVEL OF EVIDENCE: III, therapeutic.
Subject(s)
Fracture Fixation, Intramedullary , Hip Fractures , Proximal Femoral Fractures , Humans , Aged , Anesthetics, Local , Bone Nails/adverse effects , Retrospective Studies , Anesthesia, Local/adverse effects , Hip Fractures/surgery , Femur , Fracture Fixation, Intramedullary/methods , Treatment OutcomeABSTRACT
BACKGROUND: Implant cut-out or cut-through remains a common cause of cephalomedullary nail failure and patient morbidity following surgical treatment of intertrochanteric femur fractures. In patients not suitable for conversion to total hip arthroplasty, which can involve long operation times and substantial blood loss, as well as a higher risk of periprosthetic fracture and dislocation postoperatively, revision with another internal fixation is an alternative option. If the femoral head can be preserved as much as possible to avoid eventual joint replacement while the internal fixation failure is solved, the quality of life of patients will be significantly improved. CASE PRESENTATION: This current case describes a successful clinical use of a salvage procedure that allows the surgeon to avoid joint arthroplasty using INTERTAN to solve internal fixation failure caused by cut-through of Proximal Femoral Nail Antirotation-II (PFNA-II). Four years after closed reduction and internal fixation of the right femur, the patient had immobilizing right hip pain and mobility disorder. X-ray examination revealed contraction of the neck of the right femur and cut-through of the helical blade of the PFNA-II. After the revision operation, he recovered well and presented no grown pain or discomfort in weight-bearing. Conventional radiographs at 1-year follow-up showed a healed fracture, with no implant migration. CONCLUSION: Main nail exchange and revision with INTERTAN can be considered a salvage procedure in selected cases to revise a failed fixation with PFNA, which solves internal fixation failure as well as preserves the femoral head.
Subject(s)
Fracture Fixation, Intramedullary , Hip Fractures , Male , Humans , Bone Nails/adverse effects , Quality of Life , Fracture Fixation, Intramedullary/methods , Hip Fractures/surgery , Fracture Fixation, Internal , Treatment Outcome , Retrospective StudiesABSTRACT
PURPOSE: The optimal means of local antibiotic delivery for fracture related infection is unknown. Until now, intramedullary application of calcium sulphate based local antibiotics has been challenging. We report on the use of a newly available mode of preparation and delivery: the Stimulan Bullet Mat and Introducer (Biocomposites Ltd, Staffordshire, England). METHODS: A retrospective analysis of prospectively collected data for infection cases at two separate tertiary referral institutions was performed. We included cases of long bone FRI with a retained intramedullary nail, treated with a single stage protocol of metalwork removal, debridement, local antibiotic application using the novel mould and applicator, with additional bony stabilisation and soft tissue reconstruction where required. RESULTS: All 13 patients achieved infection remission rate with an average follow-up of 19.7 months (range 12-28). All 6 patients with infection around an unhealed fracture achieved union at an average 8 months (range 4-12) from debridement. No patients developed aseptic wound leak. CONCLUSIONS: Antibiotic impregnated calcium sulphate can be used safely as part of a single stage treatment protocol for the treatment of long bone fracture related infection following intramedullary nailing. We have demonstrated high rates of infection remission and union, using a newly available intramedullary applicator.
Subject(s)
Fracture Fixation, Intramedullary , Tibial Fractures , Humans , Anti-Bacterial Agents/therapeutic use , Calcium Sulfate/therapeutic use , Retrospective Studies , Fracture Fixation, Intramedullary/adverse effects , Fracture Fixation, Intramedullary/methods , Tibial Fractures/surgery , Bone Nails , Fracture Healing , Treatment OutcomeABSTRACT
Pseudoaneurysm is a rare complication after intertrochanteric fracture fixation. Herein, we present a rare case of late development of a pseudoaneurysm with silent clinical symptoms. The case was a 91-year-old woman treated with proximal femoral nailing and cerclage wiring. Postoperatively, the patient was able to ambulate with a walker without abnormal symptoms. During the follow-ups, the radiographic images showed progressive cortical scalloping on the medial femoral shaft. Ultrasonography revealed a yin-yang sign, and a CT scan confirmed a pseudoaneurysm at the profunda femoris artery (PFA). In this case, many possible causes of pseudoaneurysm were hypothesized. We showed that the excessive displaced, long spiral pattern of an intertrochanteric fracture, which was irreducible by a closed technique, is the risk of a PFA injury. An atherosclerotic vessel was seen in preoperative radiography, indicating poor vessel elasticity which may be a risk of vessel tear during fracture reduction using multiple reduction instruments in excessive displaced fracture. Moreover, over-penetration when drilling should not be overlooked. We also discuss the predisposing factors, surgical techniques which may lead to this type of PFA injury and summarize the literature of pseudoaneurysms related to intertrochanteric fracture fixation.
Subject(s)
Aneurysm, False , Fracture Fixation, Intramedullary , Hip Fractures , Female , Humans , Aged, 80 and over , Fracture Fixation, Intramedullary/adverse effects , Fracture Fixation, Intramedullary/methods , Aneurysm, False/diagnostic imaging , Aneurysm, False/etiology , Aneurysm, False/surgery , Treatment Outcome , Fracture Fixation, Internal/methods , Hip Fractures/surgery , Hip Fractures/complications , Iatrogenic Disease , Bone Nails/adverse effectsABSTRACT
BACKGROUND Kinesiology tape indications of use include pain mitigation, neurosensory input, and promotion of circulation. Current evidence suggests that residual functional limitations following intramedullary nailing of the femoral shaft may be due to soft tissue injury and compromise. This retrospective study from a single center aimed to compare the effects of kinesiology taping on edema of the lower limb in 14 patients following intramedullary nailing for femoral shaft fracture. MATERIAL AND METHODS The randomized control trial design consisting of 2 groups totaling 14 patients. The intervention group (n=7) received standard therapy and kinesiology tape decompression/fan application. The control group (n=7) received standard therapy with no kinesiology tape. Outcome measures included limb girth tape measurements, Visual Analog Scale (VAS) for pain, involved knee ROM goniometry, and Timed Up and Go (TUG). RESULTS Results of this study showed there was a decrease in limb volume in the control group and an increase in limb volume in the intervention group. Both groups had improvements in TUG scores. The only statistically significant finding was among the control group, which had a decrease of 1.6 in mean VAS score before and after IM nailing (P=0.010). CONCLUSIONS In this study from a single center, kinesiology tape in patients with intramedullary nailing for femoral shaft fracture did not significantly reduce the volume of the lower limb, reduce pain, or improve postoperative mobility. The only significant improvement from the use of kinesiology tape was improved active knee extension due to improvement in quadriceps force.
Subject(s)
Femoral Fractures , Fracture Fixation, Intramedullary , Bone Nails , Edema , Femoral Fractures/surgery , Fracture Fixation, Intramedullary/methods , Humans , Lower Extremity , Range of Motion, Articular , Retrospective Studies , Treatment OutcomeABSTRACT
BACKGROUND: Prior reports of the DePuy Synthes Trochanteric Fixation Nail Advanced (TFNA) revealed a potential mode of fatigue failure at the proximal screw aperture following fixation of extracapsular hip fractures. We sought to compare the revision risk between the TFNA and its prior-generation forebear, the Trochanteric Fixation Nail (TFN). METHODS: A retrospective cohort study was performed using data from a U.S. integrated health-care system's hip fracture registry. The study sample comprised patients who underwent cephalomedullary nail fixation for hip fracture with a TFN (n = 4,007) or TFNA (n = 3,972) from 2014 to 2019. We evaluated the charts and radiographs for patients who underwent any revision. Multivariable Cox regression was used to evaluate the risk of revision related to the index fracture. RESULTS: At the 3-year follow-up, the cumulative probability of revision related to the index fracture was 1.8% for the TFN and 1.9% for the TFNA. After adjustment for covariates, no difference was observed in revision risk (hazard ratio [HR], 1.18 [95% confidence interval (CI), 0.80 to 1.75]; p = 0.40) for the TFNA compared with the TFN. The TFNA was associated with a higher risk of revision for nonunion than the TFN (HR, 1.86 [95% CI, 1.11 to 3.12]; p = 0.018). At the 3-year follow-up, implant breakage was 0.06% for the TFN and 0.2% for the TFNA; with regard to aperture failures related to the index fracture, there were 1 failure for the TFN group and 3 failures for the TFNA group. CONCLUSIONS: In a large cohort from a U.S. hip fracture registry, the TFNA had an overall revision rate that was similar to that of the earlier TFN, with implant breakage being a rare revision reason for both groups. Chart and radiographic review found that the TFNA was associated with a higher risk of revision for nonunion. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Subject(s)
Fracture Fixation, Intramedullary , Hip Fractures , Bone Nails , Cohort Studies , Fracture Fixation, Intramedullary/adverse effects , Hip Fractures/surgery , Humans , Retrospective StudiesABSTRACT
BACKGROUND: Femoral intertrochanteric fractures (ITF) occur frequently in the elderly, accounting for 45% of all hip fractures. Postoperative anemia after fracture tends to cause ischemia, hypoxia in cells, tissues and organs, increasing the rate of blood transfusion, risk of infection, disability and mortality. Meanwhile, traditional Chinese medicine is widely used in the treatment of anemia for activating blood circulation and removing blood stasis. METHODS: This study is a prospective, outcome assessor-, and data analyst-blinded randomized controlled clinical trial. The objective of this proposed study was to investigate whether Shengyu Decoction could improve the symptoms of anemia after proximal femoral nail antirotation in elderly ITF patients. After qualifying for screening, patients will be randomized into 2 groups with an allocation ratio of 1:1. Hemoglobin concentration, HBL, and HHS score are outcome measurements. The other outcomes also included time to get out of bed, discharge to home, 30-day readmission rates, and mortality. DISCUSSION: ITF is commonly occurring in senior citizens, and those who are senior in age generally suffer 1 or more basic diseases, whose nutritional status is already poor. Trauma and surgical stimulation not only aggravate the existing disease or induce corresponding cardiovascular complications, but also worsen the nutritional status, which can easily cause postoperative anemia in patients. Because of the limited clinical modalities available for the treatment of postoperative anemia after fracture surgery, and most of them have various side effects that are not easily tolerated by the elderly. Therefore, from a traditional Chinese medicine perspective, we proposed a protocol using mild Chinese herbal decoction to treat postoperative anemia in ITF.Registration number: OSF Registration number: DOI 10.17605/OSF.IO/JQ6ZF.
Subject(s)
Anemia/drug therapy , Bone Nails , Fracture Fixation, Intramedullary , Hip Fractures/surgery , Aged , Anemia/etiology , Drugs, Chinese Herbal , Humans , Postoperative Complications , Prospective Studies , Randomized Controlled Trials as Topic , Treatment OutcomeABSTRACT
BACKGROUND: Pathologic fracture of the long bones is a common complication of bone metastases. Intramedullary nail stabilization can be used prophylactically (for impending fractures) or therapeutically (for completed fractures) to preserve mobility and quality of life. However, local disease progression may occur after such treatment, and there is concern that surgical instrumentation and the intramedullary nail itself may seed tumor cells along the intramedullary tract, ultimately leading to loss of structural integrity of the construct. Identifying factors associated with local disease progression after intramedullary nail stabilization would help surgeons predict which patients may benefit from alternative surgical strategies. QUESTIONS/PURPOSES: (1) Among patients who underwent intramedullary nail stabilization for impending or completed pathologic fractures of the long bones, what is the risk of local progression, including progression of the existing lesion and development of a new lesion around the nail? (2) Among patients who experience local progression, what proportion undergo reoperation? (3) What patient characteristics and treatment factors are associated with postoperative local progression? (4) What is the difference in survival rates between patients who experienced local progression and those with stable local disease? METHODS: Between January 2013 and December 2019, 177 patients at our institution were treated with an intramedullary nail for an impending or completed pathologic fracture. We excluded patients who did not have a pathologic diagnosis of metastasis before fixation, who were younger than 18 years of age, who presented with a primary soft tissue mass that eroded into bone, and who experienced nonunion from radiation osteitis or an avulsion fracture rather than from metastasis. Overall, 122 patients met the criteria for our study. Three fellowship-trained orthopaedic oncology surgeons involved in the care of these patients treated an impending or pathologic fracture with an intramedullary nail when a long bone lesion either fractured or was deemed to be of at least 35% risk of fracture within 3 months, and in patients with an anticipated duration of overall survival of at least 6 weeks (fractured) or 3 months (impending) to yield palliative benefit during their lifetime. The most common primary malignancy was multiple myeloma (25% [31 of 122]), followed by lung carcinoma (16% [20 of 122]), breast carcinoma (15% [18 of 122]), and renal cell carcinoma (12% [15 of 122]). The most commonly involved bone was the femur (68% [83 of 122]), followed by the humerus (27% [33 of 122]) and the tibia (5% [6 of 122]). A competing risk analysis was used to determine the risk of progression in our patients at 1 month, 3 months, 6 months, and 12 months after surgery. A proportion of patients who ultimately underwent reoperation due to progression was calculated. A univariate analysis was performed to determine whether lesion progression was associated with various factors, including the age and sex of the patient, use of adjuvant therapies (radiation therapy at the site of the lesion, systemic therapy, and antiresorptive therapy), histologic tumor type, location of the lesion, and fracture type (impending or complete). Patient survival was assessed with a Kaplan-Meier curve. A p value < 0.05 was considered significant. RESULTS: The cumulative incidence of local tumor progression (with death as a competing risk) at 1 month, 3 months, 6 months, and 12 months after surgery was 1.9% (95% confidence interval 0.3% to 6.1%), 2.9% (95% CI 0.8% to 7.5%), 3.9% (95% CI 1.3% to 8.9%), and 4.9% (95% CI 1.8% to 10.3%), respectively. Of 122 patients, 6% (7) had disease progression around the intramedullary nail and 0.8% (1) had new lesions at the end of the intramedullary nail. Two percent (3 of 122) of patients ultimately underwent reoperation because of local progression. The only factors associated with progression were a primary tumor of renal cell carcinoma (odds ratio 5.1 [95% CI 0.69 to 29]; p = 0.03) and patient age (difference in mean age 7.7 years [95% CI 1.2 to 14]; p = 0.02). We found no associations between local disease progression and the presence of visceral metastases, other skeletal metastases, radiation therapy, systemic therapy, use of bisphosphonate or receptor activator of nuclear factor kappa-B ligand inhibitor, type of fracture, or the direction of nail insertion. There was no difference in survivorship curves between those with disease progression and those with stable local disease (= 0.36; p = 0.54). CONCLUSION: Our analysis suggests that for this population of patients with metastatic bone disease who have a fracture or impeding fracture and an anticipated survival of at least 6 weeks (completed fracture) or 3 months (impending fracture), the risk of experiencing local progression of tumor growth and reoperations after intramedullary nail stabilization seems to be low. Lesion progression was not associated with the duration of survival, although this conclusion is limited by the small number of patients in the current study and the competing risks of survival and local progression. Based on our data, patients who present with renal cell carcinoma should be cautioned against undergoing intramedullary nailing because of the risk of postoperative lesion progression. LEVEL OF EVIDENCE: Level III, therapeutic study.
Subject(s)
Carcinoma, Renal Cell , Fracture Fixation, Intramedullary , Fractures, Bone , Fractures, Spontaneous , Kidney Neoplasms , Bone Nails/adverse effects , Child , Disease Progression , Female , Fractures, Bone/etiology , Fractures, Spontaneous/diagnostic imaging , Fractures, Spontaneous/etiology , Fractures, Spontaneous/surgery , Humans , Male , Quality of Life , Retrospective Studies , Treatment OutcomeABSTRACT
Background and purpose - We noted several adverse events in patients in whom the first version of the STRYDE limb-lengthening nail (NuVasive Specialized Orthopaedics, San Diego, CA) had been implanted. Pain, osteolysis, periosteal reactions, and cortical hypertrophy at the nail junction were noted. Here, we present the analysis of 23 retrieved STRYDE implants.Materials and methods - We undertook visual inspection of the retrieved nails and screws, mechanical evaluation of the junction, micro-CT analyses, microscopic inspection of the bushing, screws, screw holes, and separated parts of the implants. Positive material identification (PMI) and energy-dispersive X-ray spectroscopy (EDS) were used to analyze the chemical composition. The hardness of the material was also investigated.Results - 20/23 retrieved nails had visible signs of corrosion, i.e., discoloration at the telescopic junction. Micro-CT verified corrosion attacks in 12/12 scanned bushings. Corrosion, predominantly mechanically assisted crevice corrosion, was observed at the locking screws and screw holes in 20/23 nails. Biological material inside the nail was observed in addition to oozing from the junction of 2 nails during hardware removal, which was experimentally reproducible. Notably, the mechanical construction of the bushing changed from PRECICE P2 to STRYDE nails.Interpretation - STRYDE nails are not hermetically sealed, and liquid can pass the bushing. Biodur 108 itself is corrosion resistant; however, mechanically assisted crevice corrosion of the bushing, locking screws, and screw holes may be aggravated due to manufacturing aiming for increased strength and hardness of the alloy.Observing several adverse events, we recently published a nationwide cross-sectional analysis of all 30 STRYDE limb- lengthening nails (NuVasive, Specialized Orthopedics, San Diego, CA) that were implanted in Denmark (Rölfing et al. 2021a). 27/30 STRYDE nails have now been removed and we present data from metallurgical analysis of 23 of the retrieved implants.
Subject(s)
Bone Lengthening/instrumentation , Bone Nails/adverse effects , Bone Screws/adverse effects , Adolescent , Adult , Aged , Child , Corrosion , Cross-Sectional Studies , Denmark , Device Removal , Femur/surgery , Humans , Middle Aged , Tibia/surgery , Young AdultABSTRACT
OBJECTIVES: To examine the feasibility of a novel anesthetic option for hip fracture fixation with short cephalomedullary nails. DESIGN: Retrospective cohort study. SETTING: The study setting involved an urban, academic Level 1 trauma center, a tertiary care academic medical center, and an orthopaedic specialty hospital. PATIENTS/PARTICIPANTS: Twenty recent and 40 risk-matched (1:1:1 by anesthesia type) historical hip fracture patients were included in the study. INTERVENTION: All patients with an OTA/AO 31.A1-3 intertrochanteric hip fracture presenting from October 1, 2019 to March 31, 2020 treated with a short cephalomedullary nail underwent a new intraoperative anesthesia protocol using monitored anesthesia care (MAC) and soft-tissue infiltration with local anesthesia (STILA). MAIN OUTCOME MEASUREMENTS: Intraoperative measures, postoperative pain scores, narcotic and acetaminophen use, hospital quality measures, and inpatient cost. RESULTS: A total of 60 patients (20 each: MAC, general, and spinal) were identified. There were differences among the groups regarding mean minimum and maximum intraoperative heart rate with MAC-STILA protocol demonstrating the best maintenance of normal heart rate parameters (60-100 beats per minute). For the first 3 hours postoperatively, MAC-STILA patients reported consistently lower pain scores (visual analog scale <1) than spinal or general patients (visual analog scale > 1). Through 48 hours postoperatively, MAC-STILA narcotic usage was similar to that of the spinal cohort and approximately 5 times less than the general cohort. There were no differences in procedural time, length of stay, minor or major complications, inpatient and 30-day mortality, or 30-day readmissions, or postoperative ambulatory distance. There was no difference in inpatient cost among cohorts. CONCLUSIONS: This feasibility study demonstrates safety for the MAC-STILA protocol with comparison to spinal and general anesthesia. The MAC-STILA protocol is a viable option for treatment of OTA/AO 13.A1-3 intertrochanteric fractures with a short cephalomedullary nail and may be the preferred method for patients with severe medical comorbidities or relative contraindications to general and/or spinal anesthesia. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
Subject(s)
Anesthetics , Fracture Fixation, Intramedullary , Hip Fractures , Anesthesia, Local , Bone Nails , Hip Fractures/surgery , Humans , Retrospective Studies , Treatment OutcomeABSTRACT
Presentamos el primer reporte de caso en paciente adulto con virus de la inmunodeficiencia humana (VIH + ) con fractura por fragilidad en fémur proximal asociada al uso de terapia antirretroviral (TARV) con fumarato de disoproxilo de tenofovir (FDT) en Chile. Actualmente, los pacientes diagnosticados con VIH inician tratamiento precoz con TARV, lo que implica mayor cantidad de años de exposición a los fármacos de la terapia. El tiempo de exposición acumulado al FDT se ha asociado a disminución de la densidad mineral ósea y falla renal progresiva, pudiendo el paciente desarrollar síndrome de Fanconi adquirido y osteomalacia, con riesgo aumentado de fractura. Presentamos el caso de un hombre de 44 años, VIH+ , evaluado en urgencia tras caída a nivel que resultó en fractura patológica del fémur proximal. Los exámenes de ingreso destacaron hipocalemia, hipocalcemia, hipofosfatemia e hipovitaminosis D. Se realizó manejo multidisciplinario, con suspensión del FDT, un cambio en la TARV, y suplementación con calcio y carga de vitamina D. Se realizó reducción cerrada y fijación con clavo cefalomedular largo, que evolucionó favorablemente con rehabilitación motora precoz; el paciente recuperó su funcionalidad previa, y se observó consolidación ósea a las 12 semanas. La aparición de dolor osteomuscular en pacientes VIH+ en TARV debe levantar alta sospecha clínica de efecto adverso a medicamento; el seguimiento de estos pacientes debe incluir el control seriado de la función renal y de los niveles séricos de calcio y fósforo. La búsqueda y sospecha de estas complicaciones permitiría una intervención precoz, mejorando la condición de los pacientes y previniendo fracturas patológicas.
We present the first case report of a human immunodeficiency virus (HIV)-positive adult patient with a fragility fracture of the proximal femur associated with antiretroviral therapy (ART) with tenofovir disoproxil fumarate (TDF) in Chile. Currently, patients diagnosed with HIV start ART early, resulting in more years of exposure to these drugs. The accumulated exposure time to TDF has been associated with a decreased bone mineral density and progressive renal failure, potentially leading to acquired Fanconi syndrome, osteomalacia, and an increased risk of fracture. We present a case of a 44-year-old, HIV-positive man assessed at the emergency room after a fall from standing height which resulted in a proximal femoral pathological fracture. Laboratory findings at admission revealed hypokalemia, hypocalcemia, hypophosphatemia, and hypovitaminosis D. Multidisciplinary management was performed, with TDF discontinuation, ART change, and supplementation with calcium and vitamin D. Closed reduction and fixation with a long cephalomedullary nail was successful, with early motor rehabilitation, functional recovery, and bone consolidation at 12 weeks. Musculoskeletal pain in HIV-positive patients on ART must raise the clinical suspicion of an adverse drug effect; the follow-up of these subjects must include serial monitoring of renal function and serum calcium and phosphorus levels. Screening and suspicion of such complications would enable an early intervention, improving the patients' condition and preventing pathological fractures.
Subject(s)
Humans , Male , Adult , Anti-HIV Agents/adverse effects , Femoral Fractures/chemically induced , Femoral Fractures/therapy , Tenofovir/adverse effects , Vitamin D/therapeutic use , Bone Nails , Calcium/therapeutic use , Closed Fracture Reduction , Fracture Fixation, Intramedullary/instrumentationABSTRACT
BACKGROUND: The incidence of intramedullary infection is increasing with increased use of intramedullary fixation for long bone fractures. However, appropriate treatment for infection after intramedullary nailing is unclear. The purpose of this study was to report the results of our treatment protocol for infection after intramedullary nailing: intramedullary nail removal, local debridement, reaming and irrigation, and antibiotic-loaded calcium sulfate implantation with or without segmental bone resection and distraction osteogenesis. METHODS: We retrospectively reviewed the records of patients with an infection after intramedullary nailing treated from 2014 to 2017 at our center. Patients with follow-up of less than 24 months, received other treatment methods, or those with serious medical conditions were excluded from the analysis. Patients met the criteria were treated as described above, followed by distraction osteogenesis in 9 cases to repair bone defect. The infection remission rate, infection recurrence rate, and post-operative complication rates were assessed. RESULTS: A total of 19 patients were included in the analysis. All of patients had satisfactory outcomes with an average follow-up of 38.1 ± 9.4 months (range, 24 to 55 months). Eighteen patients (94.7%) achieved infection remission; 1 patient (5.3%) developed a reinfection that resolved after repeat debridement. Nine patients with bone defects (average size 4.7 ± 1.3 cm; range, 3.3 to 7.6 cm) were treated with bone transport which successfully restored the length of involved limb. The mean bone transport duration was 10.7 ± 4.0 months (range, 6.7 to 19.5 months). The majority of patients achieved full weight bearing and became pain free during the follow-up period. Postoperative complications mainly included prolonged aseptic drainage (7/19; 36.8%), re-fracture (1/19; 5.3%) and joint stiffness, which were successfully managed by regular dressing changes and re-fixation, respectively. CONCLUSION: Intramedullary nail removal, canal reaming and irrigation, and antibiotic-loaded calcium sulfate implantation (with or without distraction osteogenesis) is effective for treating infections after intramedullary nailing.
Subject(s)
Bone Nails , Fracture Fixation, Intramedullary , Anti-Bacterial Agents , Calcium Sulfate , Fracture Fixation, Intramedullary/adverse effects , Fracture Healing , Humans , Retrospective Studies , Treatment OutcomeABSTRACT
OBJECTIVE: To compare the clinical efficacy under local anesthesia and general anesthesia proximal femoral nail anti-rotation(PFNA) fixation for intertrochanteric fracture of femur in high risk patients. METHODS: From February 2018 to February 2019, 32 patients underwent PFNA operation due to intertrochanteric fracture of femur, including 16 patients undergoing PFNA operation under local anesthesia, 9 males and 7 females, aged 54 to 98 (82.43±9.30) years and hospitalized for (10.94±5.30) days;16 patients undergoing PFNA operation under general anesthesia, 6 males and 10 females, aged 51 to 83 (72.69±9.48) years and hospitalized for (12.88±4.12) days. The patients' gender, age, fracture AO classification, preoperative VAS (visual analogue score), preoperative ASA condition grade, postoperative 1st day resting state VAS, hospitalization cost and length of stay were recorded. RESULTS: All patients recovered well, the wound healed well, and the ability of lower limb activity was restored. The average follow-up time was 4.6 months. There was significant difference in age between two groups (P< 0.05);there was no significant difference in sex ratio, AO classification of fracture and VAS before operation (P>0.05). There was no significant difference on ASA between two groups (P>0.05), but there was significant difference on ASA≥grade â ¢ between two groups (P<0.05). In local anesthesia group, VAS pain score was 4.19±1.50, which was tolerable. There was no significant difference in postoperative 1st day resting state VAS, average hospitalization cost and average length of stay between two groups(P>0.05). CONCLUSION: Under the multi-disciplinary diagnosisand treatment mode, the method of PFNA operation is safe and feasible, the patients with local anesthesia are older, and the proportion of patients with ASA≥grade â ¢ is higher, which is better for some elderly high-risk patients than general anesthesia.
Subject(s)
Femoral Fractures , Fracture Fixation, Intramedullary , Aged , Aged, 80 and over , Anesthesia, Local , Bone Nails , Female , Femoral Fractures/surgery , Humans , Male , Middle Aged , Retrospective Studies , Treatment OutcomeABSTRACT
OBJECTIVE@#To compare the clinical efficacy under local anesthesia and general anesthesia proximal femoral nail anti-rotation(PFNA) fixation for intertrochanteric fracture of femur in high risk patients.@*METHODS@#From February 2018 to February 2019, 32 patients underwent PFNA operation due to intertrochanteric fracture of femur, including 16 patients undergoing PFNA operation under local anesthesia, 9 males and 7 females, aged 54 to 98 (82.43±9.30) years and hospitalized for (10.94±5.30) days;16 patients undergoing PFNA operation under general anesthesia, 6 males and 10 females, aged 51 to 83 (72.69±9.48) years and hospitalized for (12.88±4.12) days. The patients' gender, age, fracture AO classification, preoperative VAS (visual analogue score), preoperative ASA condition grade, postoperative 1st day resting state VAS, hospitalization cost and length of stay were recorded.@*RESULTS@#All patients recovered well, the wound healed well, and the ability of lower limb activity was restored. The average follow-up time was 4.6 months. There was significant difference in age between two groups (0.05). There was no significant difference on ASA between two groups (>0.05), but there was significant difference on ASA≥grade Ⅲ between two groups (0.05).@*CONCLUSION@#Under the multi-disciplinary diagnosisand treatment mode, the method of PFNA operation is safe and feasible, the patients with local anesthesia are older, and the proportion of patients with ASA≥grade Ⅲ is higher, which is better for some elderly high-risk patients than general anesthesia.