Surgical management and outcomes following atypical subtrochanteric femoral fractures - results from a matched-pair analysis of the registry for geriatric trauma of the German Trauma Society.

BACKGROUND AND OBJECTIVES: The outcomes of patients with atypical subtrochanteric fractures (ASFs) remain unclear. Data from a large international geriatric trauma registry were analysed to examine the outcome of patients with ASFs compared to patients with typical osteoporotic subtrochanteric fractures (TSFs). MATERIALS AND METHODS: Data from the Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (ATR-DGU) were analysed. All patients treated surgically for ASFs or TSFs were included in this analysis. Across both fracture types, a paired matching approach was conducted, where statistical twins were formed based on background characteristics sex, age, American Society of Anesthesiologists (ASA) score and walking ability. In-house mortality and mortality rates at the 120-day follow-up, as well as mobility at 7 and 120 days, the reoperation rate, hospital discharge management, the hospital readmission rate at the 120-day follow-up, health-related quality of life, type of surgical treatment and anti-osteoporotic therapy at 7 and 120 days, were assessed as outcome measures using a multivariate logistic regression analysis. RESULTS: Amongst the 1,800 included patients, 1,781 had TSFs and 19 had ASFs. Logistic regression analysis revealed that patients with ASFs were more often treated with closed intramedullary nailing (RR = 3.59, p < 0.001) and had a higher probability of vitamin D supplementation as osteoporosis therapy at 120 days (RR = 0.88, p < 0.002). Patients with ASFs were also more likely to live at home after surgery (RR = 1.43, p < 0.001), and they also tended to continue living at home more often than patients with TSFs (RR = 1.33, p < 0.001). Accordingly, patients with TSFs had a higher relative risk of losing their self-sufficient living status, as indicated by increased rates of patients living at home preoperatively and being discharged to nursing homes (RR = 0.19, p < 0.001) or other hospitals (RR = 0.00, p < 0.001) postoperatively. CONCLUSIONS: Surgical treatment of ASFs was marked by more frequent use of closed intramedullary fracture reduction. Furthermore, patients with ASFs were more likely to be discharged home and died significantly less often in the given timeframe. The rate of perioperative complications, as indicated by nonsignificant reoperation rates, as well as patient walking abilities during the follow-up period, remained unaffected.

Pediatric femoral shaft fracture requiring revision surgery for nonunion associated with vitamin D and K deficiencies: a case report.

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.

Augmentative Plating in the Treatment of Femoral Nonunion after Intramedullary Nail Fixation.

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.

Comparison of Proximal Anti-Rotation Intramedullary Nail and Femoral Head Replacement for the Treatment of Femoral Intertrochanteric Fractures in Elderly Patients.

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.

Local anesthetic with monitored anesthesia care in cephalomedullary nailing of proximal femur fractures.

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.

Successful Revision with INTERTAN for a Blade Cut Through in PFNA Fixation: A Case Report.

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.

Silent iatrogenic pseudoaneurysm after intertrochanteric fracture fixation with proximal femoral nailing and cerclage wiring: case report and review of literature.

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.

Intramedullary application of local antibiotic bullets for the treatment of long bone fracture related infection.

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.

A Retrospective Study on the Effects of Kinesiology Taping on Edema of the Lower Limb in 14 Patients Following Intramedullary Nailing for Femoral Shaft Fracture.

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.

Safety and Performance of Bone-Anchored Prostheses in Persons with a Transfemoral Amputation: A 5-Year Follow-up Study.

BACKGROUND: For almost 30 years, bone-anchored prostheses have offered an alternative solution to prosthetic sockets by attaching the artificial limb directly to the femoral residuum by means of an osseointegration implant. Osseointegration implant surgery was introduced in our center in 2009. The aim of the present study is to report on safety, prosthesis-wearing time, and health-related quality-of-life (HRQoL) for patients with femoral bone-anchored prostheses during a 5-year follow-up period. METHODS: All patients who underwent implantation of a press-fit osseointegration implant between May 2009 and November 2013 were eligible for the present study. Implantation was performed in 2 stages. Adverse events included infectious complications (grade 1 to 4), aseptic loosening, breakage, stoma-redundant tissue, and stoma hypergranulation. Prosthesis-wearing time and HRQoL were measured with the Questionnaire for Persons with a Transfemoral Amputation (Q-TFA) prosthetic use score and global score, respectively. RESULTS: Thirty-nine of 42 eligible patients were included. Thirty patients (77%) presented with some kind of infection (156 events in total), with 148 (95%) events being classified as grade 1 or 2 and 8 events (5%) being classified as grade 3; the latter 8 events occurred in 4 patients. There were no instances of septic loosening. The intramedullary stem of the osseointegration implant broke in 2 patients. In total, soft-tissue refashioning had to be done 30 times in 14 patients. The Q-TFA median prosthetic use and global scores improved significantly from 71 to 100 and from 33 to 75, respectively (p < 0.001). CONCLUSIONS: Despite the adverse events, patient prosthetic use and HRQoL improved significantly. Grade-1 and 2 infections were frequent but could mostly be treated with nonoperative measures. Most infections seemed to occur in the first 2 years and did not lead to deep infections. Two broken intramedullary stems were revised successfully. Current developments focus on reduction of infectious complications and prevention of osseointegration implant breakage. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Growth factor-mediated augmentation of long bones: evaluation of a BMP-7 loaded thermoresponsive hydrogel in a murine femoral intramedullary injection model.

BACKGROUND: Due to our aging population, an increase in proximal femur fractures can be expected, which is associated with impaired activities of daily living and a high risk of mortality. These patients are also at a high risk to suffer a secondary osteoporosis-related fracture on the contralateral hip. In this context, growth factors could open the field for regenerative approaches, as it is known that, i.e., the growth factor BMP-7 (bone morphogenetic protein 7) is a potent stimulator of osteogenesis. Local prophylactic augmentation of the proximal femur with a BMP-7 loaded thermoresponsive hydrogel during index surgery of an osteoporotic fracture could be suitable to reduce the risk of further osteoporosis-associated secondary fractures. The present study therefore aims to test the hypothesis if a BMP-7 augmented hydrogel is an applicable carrier for the augmentation of non-fractured proximal femurs. Furthermore, it needs to be shown that the minimally invasive injection of a hydrogel into the mouse femur is technically feasible. METHODS: In this study, male C57BL/6 mice (n = 36) received a unilateral femoral intramedullary injection of either 100 µl saline, 100 µl 1,4 Butan-Diisocyanat (BDI)-hydrogel, or 100 µl hydrogel loaded with 1 µg of bone morphogenetic protein 7. Mice were sacrificed 4 and 12 weeks later. The femora were submitted to high-resolution X-ray tomography and subsequent histological examination. RESULTS: Analysis of normalized CtBMD (Cortical bone mineral density) as obtained by X-ray micro-computed tomography analysis revealed significant differences depending on the duration of treatment (4 vs 12 weeks; p < 0.05). Furthermore, within different anatomically defined regions of interest, significant associations between normalized TbN (trabecular number) and BV/TV (percent bone volume) were noted. Histology indicated no signs of inflammation and no signs of necrosis and there were no cartilage damages, no new bone formations, or new cartilage tissues, while BMP-7 was readily detectable in all of the samples. CONCLUSIONS: In conclusion, the murine femoral intramedullary injection model appears to be feasible and worth to be used in subsequent studies that are directed to examine the therapeutic potential of BMP-7 loaded BDI-hydrogel. Although we were unable to detect any significant osseous effects arising from the mode or duration of treatment in the present trial, the effect of different concentrations and duration of treatment in an osteoporotic model appears of interest for further experiments to reach translation into clinic and open new strategies of growth factor-mediated augmentation.

Clinical application of auricular point sticking in perioperative hemostasis for elderly patients with intertrochanteric fractures of the femur.

We investigated the clinical application of auricular point sticking (APS) combined with tranexamic acid in perioperative hemostasis in elderly patients with intertrochanteric fractures of the femur.This is a prospective cohort study, and we analyzed 86 elderly patients with intertrochanteric fractures of the femur who underwent closed reduction and internal fixation with proximal femoral nail antirotation (PFNA) between January 2016 and December 2016. The patients were divided into auricular point combined with tranexamic acid group (APS group, n = 43) and tranexamic acid alone group (Control group, n = 43). APS was performed for patients using Vaccaria seeds 1 to 2 days before the operation. The 4 acupoints of hemostasis, including spleen, diaphragm, pituitary, and adrenal gland, as well as acupoint of hip joint, were selected. Routine treatment was performed using tranexamic acid alone in the control group. Blood transfusion, intraoperative, postoperative, and total blood loss were compared between the 2 groups.This study enrolled 36 males and 50 females aged 71 to 93 years (average age: 78.5 years). There were no significant differences in gender, age, height, weight, preoperative hematocrit level, fracture classification, operative time, and hospitalization stay (P > .05). Total blood loss was lower in the APS group than the control group (244.26, 197.87-258.50 ml vs 533.94, 424.00-598.09 ml, P < .01). The blood transfusion rate was 14.0% in the APS group and 34.9% in the control group (P = .02).APS can reduce perioperative bleeding and decrease the need for blood transfusion in elderly patients with intertrochanteric fractures of the femur. This noninvasive method can be applied clinically. Randomized trials may be needed to confirm the findings.

[Photodynamic intramedullary bone stabilization of pathological fractures]. / Fotodynamische intramedulläre Knochenstabilisierung bei pathologischen Frakturen.

Pathological fractures of long tubular bones are stabilized with conventional implants. Essentially, plates and intramedullary nails are used for stabilization and are two different techniques, which compete with each other with respect to the surgical treatment. A large number of such means of osteosynthesis are commercially available but are primarily focused on acute fractures in otherwise biologically healthy bones. The pathological fracture or the treatment of impending pathological fractures due to metastatic osteolysis differs from the treatment of healthy bones in some fundamental aspects. The characteristics of pathological fractures make the development of new technologies that meet the specific needs of both the patient and the surgeon desirable. A new approach in treatment is stabilization of internal long bone fractures by the use of a cylindrical balloon implant, which is introduced into the bone via a small proximal or distal hole and then filled and expanded to a much larger diameter with a liquid monomer. The curing process is initiated with the application of blue light forming a rigid implant by polymerization (IlluminOss™). Many of the well-known disadvantages of conventional implants can be eliminated with this technology. Specifically, with respect to the irregular shape of the natural medullary canal it is possible to completely fill the medullary canal of the tubular bone. The filling of the canal provides torsional stability without the use of interlocking screws. Similarly, the use of the balloon technique enables minimally invasive surgery and furthermore permits the additive use of conventional metallic plates whenever necessary. The new balloon techniques show high primary stability in the treatment of pathological shaft fractures. In particular cases, the addition of a supplemental plate osteosynthesis is recommended.

Osteopoikilosis found incidentally in a 17-year-old adolescent with femoral shaft fracture: A case report.

RATIONALE: Osteopoikilosis is a rare and asymptomatic disease of the bone, which is often discovered occasionally on radiography for irrelevant complaints. Characterized by multiple, small, circular, or oval-shaped radiodense lesions, it may be confused with bony metastatic tumors. PATIENT CONCERNS: The present study describes a case of a 17-year-old adolescent who suffered from pain and movement limitation of his left thigh following a fall from standing height. DIAGNOSES: Plain radiographs showed spiral fracture in left femoral shaft; besides, multiple scattered sclerotic lesions of variable size were also observed over the bilateral proximal femurs, left distal femur, proximal tibia, and distal tibia and fibula through X-rays, computed tomography, and magnetic resonance imaging. The patient was finally diagnosed with left femoral shaft fracture and osteopoikilosis. INTERVENTIONS: The patient underwent reduction and internal fixation with intramedullary nail a week after injury. OUTCOMES: The patient was discharged without any complications 12 days after the surgery. At the 3-month follow-up, the patient recovered well and remained symptom-free with no changes to his sclerotic lesions. LESSONS: Although this case is not so complicated, we have to be cautious when differentiating osteopoikilosis and bony metastases in clinical practice in future, which should avoid causing undue distress to both the patients and doctors.

Rotationally Stable Screw-Anchor With Locked Trochanteric Stabilizing Plate Versus Proximal Femoral Nail Antirotation in the Treatment of AO/OTA 31A2.2 Fracture: A Biomechanical Evaluation.

OBJECTIVES: Third-generation cephalomedullary nails currently represent the gold standard in the treatment of unstable trochanteric femur fractures. Recently, an extramedullary rotationally stable screw-anchor system (RoSA) has been developed. It was designed to combine the benefits of screw and blade and to improve stability using a locked trochanteric stabilizing plate (TSP). The purpose of this study was to compare the biomechanical behavior of RoSA/TSP and the proximal femoral nail antirotation (PFNA). METHODS: Standardized AO/OTA 31A2.2 fractures were induced by an oscillating saw in 10 paired human specimens (n = 20; mean age = 85 years; range: 71-96 years). The fractures were stabilized by either the RoSA/TSP (Koenigsee Implants, Allendorf, Germany) or the PFNA (DePuy Synthes, Zuchwil, Switzerland). Femurs were positioned in 25 degrees of adduction and 10 degrees of posterior flexion and were cyclically loaded with axial sinusoidal pattern at 0.5 Hz, starting at 300 N, with stepwise increase by 300 N every 500 cycles until bone-implant failure occurred. After every load step, the samples were measured visually and radiographically. Femoral head migration was assessed. RESULTS: The stiffness at the load up to the clinically relevant load step of 1800 N (639 ± 378 N/mm (RoSA/TSP) vs. 673 ± 227 N/mm (PFNA); P = 0.542) was comparable, as was the failure load (3000 ± 787 N vs. 3780 ± 874 N; P = 0.059). Up to 1800 N, no femoral head rotation, head migration, or femoral neck shortening were observed either for RoSA/TSP or PFNA. Whereas failure of the PFNA subsumed fractures of the greater trochanter and the lateral wall, a posterior femoral neck fracture with a significantly increased femoral neck shortening (1.7 mm vs. 0 mm; P = 0.012) was the cause of failure with RoSA/TSP. This specific kind of failure was induced by a femoral neck weakening caused by the posterior TSP stabilizing screw. CONCLUSIONS: There was no significant difference in biomechanical properties between the RoSA/TSP and the PFNA for the fracture pattern tested. However, failure modes differed between the 2 implants with greater femoral neck shortening observed in the RoSA/TSP group.

Fixator-augmented flexible intramedullary nailing for osteopenic femoral shaft fractures in children.

Children with underlying metabolic bone diseases, such as osteogenesis imperfecta and spastic cerebral palsy, pose a challenge in the treatment of femoral shaft fractures. We performed flexible intramedullary nailing with supplemental monolateral external fixation in a subgroup of such patients. The external fixator assists in controlling angulation and rotation at the fracture site, and avoids the need for supplemental casting with its associated problems such as skin breakdown and difficulty with personal hygiene. We describe the surgical technique, pitfalls, and outcomes in a series of four patients with underlying osteopenia treated with external fixator-augmented flexible nailing for femoral shaft fractures.

[Congenital pseudarthrosis of lower leg treated by almost outdated method--case report].

INTRODUCTION: Congenital pseudarthrosis of tibia is a rare congenital deformity with progressive evolution. Treatment is vague and difficult, and many methods have been used--from once mandatory early amputation to contemporary operative (Ilizarov method, free microvascular fibular graft) and adjuvant methods (electrostimulation, biphosphonates, bone morphogenetic protein). We present the usage of once popular method of homologous graft insertion and intramedullary fixation. CASE OUTLINE: This is a case report of male patient with pseudarthrosis involving both crural bones (Boyd type 5), diagnosed in neonatal age. Early conservative treatment was unsuccessful, so child never initiated gait. At the age of three and a half years, operative treatment was applied: resection of pseudarthrosis on both tibia and fibula, and osteoplasty of tibia using cylindric homologous graft and intramedullary fixation with transtarsal Steinman pin, followed by long leg cast immobilization. Pin was removed after ten months, and physical therapy was initiated 1.5 year after surgery, with initial to partial weight bearing and short leg cast throughout another year. Two and a half years after surgery complete union of graft was documented, and then full weight bearing was allowed. At final visit, five years and three months after surgery, shin axis was correct, leg lengths were equal, and child had normal walk with full range of motion. X-ray showed complete union of both tibia and fibula. CONCLUSION: Despite bad prognostic factors (young age, severe deformity), utilization of obsolete and almost forgotten treatment methods can provide excellent result.

Cost effectiveness of tibial nonunion treatment: A comparison between rhBMP-7 and autologous bone graft in two Italian centres.

Current evidences show that recombinant human bone morphogenetic protein 7 (rhBMP-7, eptotermin alfa) can be considered an effective alternative to autologous bone graft (ABG) in the treatment of tibial nonunions. Few studies, so far, have analysed the costs of treating tibial nonunions with either rhBMP-7 or ABG and none of them has specifically considered the Italian situation. The aim of the present study was to capture, through observational retrospective methods, the direct medical costs associated with the treatment of tibial nonunions with rhBMP-7 or ABG in Italy and to compare the cost effectiveness of the two interventions. The secondary objective was to perform a cost-reimbursement analysis for hospitalisations associated with the two treatments. Data of 54 patients with indication for tibial nonunion were collected from existing data sources. Of these patients, 26 were treated with ABG and 28 with rhBMP-7. The study captured the direct medical costs for treating each tibial nonunion, considering both inpatient and outpatient care. The hospital reimbursement was calculated from discharge registries, based on diagnosis-related group (DRG) values. A subgroup of patients (n=30) was also interviewed to capture perceived health during the follow-up, and the quality-adjusted life years (QALYs) were subsequently computed. The two groups were similar for what concerns baseline characteristics. While the medical costs incurred during the hospitalisation associated with treatment were on average €3091.21 higher (P<0.001) in patients treated with rhBMP-7 (reflecting the product procurement costs), the costs incurred during the follow-up were on average €2344.45 higher (P=0.02) in patients treated with ABG. Considering all costs incurred from the treatment, there was a borderline statistical evidence (P=0.04) for a mean increase of €795.42, in the rhBMP-7 group. Furthermore, the study demonstrated that, without appropriate reimbursement, the hospital undergoes significant losses (P=0.003) when using rhBMP-7 instead of ABG. In contrast to these losses, in Italy, the average cost to achieve a successful outcome was €488.96 lower in patients treated with rhBMP-7 and, additionally, the cost per QALY gained was below the cost-utility threshold of $50,000.

Centromedullary manipulation and stabilization of completely displaced proximal humerus fractures in adolescents.

Completely displaced metaphyseal fractures of the proximal humerus in older children may need reduction and stabilization. The authors describe a technique for closed reduction and intramedullary stabilization of these fractures using a centromedullary pin inserted from the distal humerus through a small distal incision. This technique was used successfully in 2 adolescents. Retrograde elastic nails avoid scars in front of the shoulder, impingement problems from prominent extramedullary metal work, and further surgery of a similar magnitude to remove the metalwork. Based on the authors' experience, they recommend this method for reduction and stabilization of displaced irreducible metaphyseal fractures of the proximal humerus in older children and adolescents.

Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing.

INTRODUCTION: Treatment of lower extremity segmental bone loss is difficult. Masquelet et al. proposed a two-stage technique: first, debridement and filling of bone loss with an acrylic spacer; second, bone reconstruction by filling with cancellous bone in the space left free (following cement removal) inside the so-called self-induced periosteal membrane. In the originally described technique, the fracture site is stabilized by an external fixator, which remains in place throughout the bone healing process, i.e., often longer than 9 months with all the known disadvantages of this type of assembly. Following the principle of two-stage reconstruction, we modified the technique by reconstructing around an intramedullary-locking nail placed in the first stage. HYPOTHESIS: This technique prevents the mechanical complications related to external fixator use and provides faster resumption of weight-bearing. PATIENTS AND METHODS: Twelve patients were operated for segmental tibial bone loss greater than 6cm resulting from injury (four cases) or aseptic necrosis (one case) or septic necrosis (seven cases). All the patients were operated on in an emergency setting and the first stage was performed before the 2nd week. A free muscle flap (ten patients) or a pediculated fasciocutaneous flap (two patients) was necessary during this first step to cover the site and provide good conditions for secondary bone growth. The follow-up was 39.5 months (range, 12-94 months). RESULTS: Complete weight-bearing was resumed at a mean 4 months. After the second step, all the patients except one had apparently healed (complete weight-bearing with no pain). Five septic complications occurred after the second step, in one case leading to reconstruction failure. Four other patients had infectious complications successfully treated (as of the last follow-up) either by changing the nail in two cases or by prolonged antibiotic therapy in two other cases, with no graft loss. DISCUSSION: The use of the intramedullary nail facilitates the Masquelet technique by allowing the patient to resume weight-bearing more quickly and avoiding secondary fractures. However, the risk of sepsis remains high but can be controlled without compromising the final bone union in four cases out of five. LEVEL OF EVIDENCE: Level IV. Retrospective study.