Teriparatide Does not Have Beneficial Effects on Bone Healing in Complete Atypical Femur Fractures.

Teriparatide is an anabolic drug sometimes administered to patients who have atypical femoral fracture (AFF). However, whether teriparatide has beneficial effects on bone healing remains uncertain. The present study aimed to analyze the association between teriparatide and bone healing in complete AFF. A total of 59 consecutive cases (58 patients) who underwent intramedullary nailing for complete AFF were categorized based on postoperative use of teriparatide into the non-teriparatide (non-TPTD, n = 34) and teriparatide groups (TPTD, n = 25). Time-to-bone union was evaluated and compared between the two groups. Additionally, multiple regression analysis was performed to evaluate factors affecting time-to-bone union. All participants were women, with a mean age of 77.6 years (range: 62-92). No significant difference in time-to-bone union was found between the non-TPTD and TPTD groups (5.5 months vs. 5.8 months, p = 0.359). Two patients in the non-TPTD group underwent reoperation (p = 0.503) due to failure caused by inadequate fixation, and both achieved bone healing after additional fixation with blocking screws. Multiple regression analysis revealed that the anterior gap of the fracture site postoperatively was a factor affecting time-to-bone union (p = 0.014). The beneficial effect of teriparatide on bone healing in complete AFF could not be confirmed. Additional randomized controlled trials are required. Nonetheless, appropriate techniques, including efforts to reduce the gap on the tensile side during the surgery, are important for reliable bone healing.

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.

Stable elastic nail application with poller K-wire for Irreducible distal radius metaphyseal-diaphyseal Junction fractures in preadolescents: a new operative technique.

BACKGROUND: Surgical treatment of irreducible distal radius diaphyseal- metaphyseal junction fractures involves difficulties as the fracture remains too proximal for K-wire fixation and too distal for the elastic stable intramedullary nail. Our study aims to present the clinical results of applying an elastic stable intramedullary nail with a poller K-wire to achieve both reduction and stable fixation. PATIENTS AND METHODS: A retrospective analysis was performed on 26 patients who underwent ESIN with a poller K-wire for distal radius diaphyseal-metaphyseal region fracture. Reduction parameters such as residual angulation and alignment were evaluated on postoperative follow-up radiographs. Changes in angular and alignment parameters on follow-up radiographs were recorded. Wrist and forearm functions were evaluated at the last follow-up. RESULT: There were 17 male and nine female patients with an average age of 10.9. The residual angulation in coronal and sagittal planes on immediate postoperative radiographs was 4.0 ± 1.62° and 3.0 ± 1.26°, respectively. The mean translation rate on immediate postoperative radiographs was 6.0 ± 1.98% and 5.0 ± 2.02% in the coronal and sagittal planes, respectively. No change was observed in translation rates in the last follow-ups. The mean angulation in the coronal and sagittal planes measured on 6th-week radiographs was 4.0 ± 1.72°and 3.0 ± 1.16°, respectively. No significant difference was observed in angular changes in the sagittal and coronal planes at the last follow-up (p > 0.05). No tendon injury or neurovascular injury was observed in any of the patients. CONCLUSION: In the surgical treatment of pediatric DRDMJ fractures, applying ESIN with poller K-wire is an effective, safe, and novel method for achieving reduction and stable fixation.

Comparative efficacy and safety of medical treatments for proximal humerus fractures: a systematic review and network meta-analysis.

BACKGROUND: Various surgical techniques and conservative therapies are useful tools for treating proximal humerus fractures (PHFs), but it is important to understand how to properly utilize them. Therefore, we performed a systematic review and network meta-analysis to compare and rank the efficacy and safety of medical treatments for PHF. METHODS: PubMed, Embase, the Cochrane Library, and the ClinicalTrials.gov databases were systematically searched for eligible randomized controlled trials (RCTs) from inception until June 2022. Conservative therapy-controlled or head-to-head RCTs of open reduction internal fixation (ORIF), intramedullary nailing (IMN), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (RTSA) used for the treatment of adult patients with PHF were included. The surface under the cumulative ranking (SUCRA) probabilities were applied to compare and rank the effects of medical treatments for PHF. RESULTS: Eighteen RCTs involving 1,182 patients with PHF were selected for the final analysis. Mostly baseline characteristics among groups were well balanced, and the imbalanced factors only included age, injury type, medial comminution, blood loss, and cognitive function in single trial. The SUCRA probabilities found that RTSA provided the best effect on the Constant-Murley score (SUCRA: 100.0%), and the disabilities of the arm, shoulder and hand (DASH) score (SUCRA: 99.0%). Moreover, HA (SUCRA: 85.5%) and RTSA (SUCRA: 68.0%) had a relatively better effect on health-related quality of life than the other treatment modalities. Furthermore, conservative therapy (SUCRA: 84.3%) and RTSA (SUCRA: 80.7%) were associated with a lower risk of secondary surgery. Finally, the best effects on the risk of complications are varied, including infection was observed with conservative therapy (SUCRA: 94.2%); avascular necrosis was observed in HA (SUCRA: 78.1%), nonunion was observed in RTSA (SUCRA: 69.6%), and osteoarthritis was observed in HA (SUCRA: 93.9%). CONCLUSIONS: This study found that RTSA was associated with better functional outcomes, while the comparative outcomes of secondary surgery and complications varied. Optimal treatment for PHF should consider patient-specific factors.

Diaphyseal forearm fracture management in adolescent patients from 2011 to 2020: A multicenter study of surgery and regional anesthesia trends.

BACKGROUND: Diaphyseal forearm fractures are common traumatic injuries among children. There has been much debate on the use of intramedullary nailing (IMN) or plate fixation in the adolescent population (10-16 years of age). Furthermore, as ultrasound technology has advanced, the safety and efficacy of ultrasound-guided axillary brachial plexus block for children has dramatically improved. Therefore, anesthesia options for adolescent patients have increased in recent years. This study aimed to investigate recent surgical and regional anesthesia trends of diaphyseal forearm fractures in patients 10 to 16 years of age in Japan through a multicenter epidemiological survey from 2011 to 2020. METHODS: This retrospective, multicenter study included 226 pediatric patients with diaphyseal forearm fracture aged 10-16 years treated from January 2011 to December 2020. We divided the patients into four groups according to the period in which they were treated: early (2011-2013), middle (2014-2016), late (2017-2019), and COVID-19 (2020). Information from medical records was used to investigate the number of surgeries, types of anesthesia administered, and internal fixation methods used for diaphyseal forearm fracture in adolescent patients during each period. RESULTS: The number of surgeries was generally constant in each period but decreased during the COVID-19 period. In the early, middle, late, and COVID-19 periods, the percentages of surgeries performed under regional anesthesia were 67.7, 85.5, 87.0, and 100% respectively (p = 0.003). During the same periods, the percentages of patients receiving IMN were 41.5, 49.3, 58.0, and 66.7%, respectively (p = 0.033). CONCLUSION: The use of IMN and regional anesthesia to treat diaphyseal forearm fracture in patients 10 to 16 years of age steadily increased during the study period from 2011 to 2020. These results indicate that regional anesthesia is safe, effective, and well-tolerated by adolescent patients. The treatment strategy for diaphyseal forearm fractures in adolescents using regional anesthesia in combination with IMN worked well and was effective during COVID-19. Our evidence suggests this trend will continue. We anticipate that our findings can be extrapolated for upper extremity fractures in adolescent patients beyond the Tokai region of Japan where the study was based.

Rotatory malunion following antegrade intramedullary femoral nailing for femoral shaft fractures: incidence and risk factors.

DESIGN: Retrospective study. SETTING: Level I academic Trauma Center. PATIENT SELECTION CRITERIA: Adult patients with femoral shaft fractures in which a bilateral computed-tomography (CT) scan of both femurs was performed, with a two years minimal follow-up. OUTCOME MEASURES AND COMPARISONS: Criteria related to the patient and the fracture were studied. We fixed the following angles, i.e. 10° and 15°, as references for calculating the RM.

Short-term complication rates of open reduction and plate fixation and intramedullary nailing in the treatment of humeral shaft fractures: a propensity score matched analysis.

INTRODUCTION: This is a retrospective cohort study designed to compare short-term postoperative complication rates between closed humeral shaft fractures treated by open reduction and internal fixation (ORIF) versus intramedullary nailing (IMN), as well as secondary independent risk factors for adverse outcomes. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using CPT codes to identify patients that underwent an open reduction and plate fixation or intramedullary nailing procedure for a closed humeral shaft fracture from 2010 to 2021. Cohorts were matched using propensity scores to account for demographic differences and rates of complications were compared between the two groups. RESULTS: From the database, a total of 4,222 patients were identified who met inclusion criteria, with 3,326 and 896 undergoing ORIF and IMN respectively. After propensity score matching, 866 of the nearest-neighbor matches were included in each cohort for a total of 1,732 patients in the final analysis. The rate of any adverse event (AAE) was significantly higher in the ORIF cohort (16.3%) than the IMN cohort (12.1%, p = 0.01). The ORIF group had higher rates of postoperative transfusion (p = 0.002), return to OR (p = 0.005), and surgical site infection (SSI, p = 0.03). After multivariate analysis, ASA class 4, increasing age, increasing operative time, and history of bleeding disorder were found to increase the risk of AAE in both ORIF and IMN patients. CONCLUSIONS: While prior studies have claimed higher complication rates in IMN patients, this study found a significantly higher short-term risk of AAE in ORIF patients when compared in matched cohorts. However, individual 30-day complication rates do not differ significantly between procedures, and both have been shown to be safe and effective tools in the management of humeral shaft fractures.

The efficacy of suprapatellar, parapatellar and infrapatellar intramedullary nailing in the treatment of tibial fractures: a systematic review and meta-analysis.

BACKGROUND: Tibial fractures are common and challenging orthopedic injuries that are commonly treated with intramedullary nailing techniques via suprapatellar (SP), parapatellar (PP), and infrapatellar (IP) approaches. This study aimed to provide a comprehensive comparative analysis of the efficacy of different treatment approaches based on clinical outcomes. METHODS: We conducted a detailed search in PubMed, Cochrane Library, Embase, and Web of Science for clinical studies comparing suprapatellar, parapatellar, and infrapatellar approaches in intramedullary nailing of tibial fractures. Inclusion criteria included randomized controlled trials and retrospective cohort studies involving patients aged 18 and older, comparing outcomes of these surgical techniques. Exclusion criteria included studies with insufficient data, non-English publications, and those focusing on non-tibial fractures. RESULTS: A total of 15 studies involving 1396 patients were included in meta-analysis. Pooled results indicated that, compared to IP nailing, the SP approach significantly reduced fluoroscopy time (MD = - 35.63, 95% CI - 39.37 to - 31.89, p < 0.001), operative time (MD = - 10.72, 95% CI - 17.30 to - 4.15, p = 0.001), pain scores (SMD = - 1.49, 95% CI - 2.36 to - 0.62, p < 0.001), and improved Lysholm scores (MD = 5.74, 95% CI 3.29 to 8.19, p < 0.001) and malalignment rate (RR = 0.24, 95% CI 0.08 to 0.68, p = 0.008). Quality of life assessments also indicated higher physical component scores for the SP group (MD = 6.68, 95% CI 5.19 to 8.17, p < 0.001). CONCLUSION: The SP approach provides significant intraoperative and postoperative benefits, reducing surgery time and improving patient outcomes in pain management and knee joint function. These findings support the SP approach as a preferred option for surgical treatment of tibial fractures.

Intramedullary nailing of proximal humerus fractures does not achieve superior functional results to non-operative treatment in the long term.

INTRODUCTION: Non-operative treatment (NOT) of proximal humerus fractures (PHF) has regained significance due to recent evidence. Additionally, positive outcomes of plate osteosynthesis and fracture arthroplasty prompt a reassessment of the role of intramedullary nailing (IMN). While favorable short and medium-term results have been documented following IMN, little is known regarding functional outcomes and quality of life in the long-term. METHODS: Data from 180 patients with dislocated PHF of Neer types III, IV and V, treated at our level-I trauma center between 2004 and 2014 using IMN or NOT therapy, were scanned. Patients were re-evaluated after a minimum of 5 years to assess functional outcomes (age- and sex-adapted Constant Score, QuickDASH), quality of life (SF12), and complications or reoperations. RESULTS: Out of the initially identified 180 patients, 51 were unavailable for follow-up (FU) and 71 had deceased during the FU period. Functional outcomes and quality of life was, therefore, assessed in 58 patients (30 IMN, 28 NOT) with an average age at injury of 68 years after a mean FU time of 10.3 ± 3.4 years. Epidemiological patient characteristics did not exhibit significant differences between the two groups (p > .05). The functional outcome assessed by age- and sex-adapted Constant Score (NOT: 74 ± 28; IMN: 68 ± 24; p = .438), QuickDASH (NOT: 25 ± 27; IMN: 31 ± 23; p = .374) or quality of life using the SF12 (p > .05) revealed no significant disparities in long-term outcomes between the treatment groups. 10 of 30 patients in the IMN group underwent surgical revision to address complications, exceeding mere implant removal. Conversely, no patient in the NOT group underwent a revision surgery during the FU period. CONCLUSIONS: In the long-term, functional and quality of life-related outcomes of IMN did not diverge significantly from those of NOT, while causing a higher incidence of follow-up interventions.

Digitally enhanced hands-on surgical training (DEHST) enhances the performance during freehand nail distal interlocking.

PURPOSE: Freehand distal interlocking of intramedullary nails remains a challenging task. Recently, a new training device for digitally enhanced hands-on surgical training (DEHST) was introduced, potentially improving surgical skills needed for distal interlocking. AIM: To evaluate whether training with DEHST enhances the performance of novices (first-year residents without surgical experience in freehand distal nail interlocking). METHODS: Twenty novices were randomly assigned to two groups and performed distal interlocking of a tibia nail in mock operation under operation-room-like conditions. Participants in Group 1 were trained with DEHST (five distal interlocking attempts, 1 h of training), while those in Group 2 did not receive training. Time, number of X-rays shots, hole roundness in the X-rays projection and hit rates were compared between the groups. RESULTS: Time to complete the task [414.7 s (range 290-615)] and X-rays exposure [17.8 µGcm2 (range 9.8-26.4)] were significantly lower in Group 1 compared to Group 2 [623.4 s (range 339-1215), p = 0.041 and 32.6 µGcm2 (range 16.1-55.3), p = 0.003]. Hole projections were significantly rounder in Group 1 [95.0% (range 91.1-98.0) vs. 80.8% (range 70.1-88.9), p < 0.001]. In Group 1, 90% of the participants achieved successful completion of the task in contrast to a 60% success rate in Group 2. This difference was not statistically significant (p = 0.121). CONCLUSIONS: In a mock-operational setting, training with DEHST significantly enhanced the performance of novices without surgical experience in distal interlocking of intramedullary nails and hence carries potential to improve safety and efficacy of this important and demanding surgical task to steepen the learning curve without endangering patients. LEVEL OF EVIDENCE: II.

Blocking screw (pin) technique to achieve an acceptable reduction in intramedullary of subtrochanteric femoral fractures: indications, techniques, and clinical outcomes.

INTRODUCTION: Subtrochanteric femur fractures treated with intramedullary nails present biomechanical benefits, early weight-bearing, and reduced soft tissue damage, promoting bone union. However, improper reduction due to muscular forces and fragmented proximal bone increases nonunion risk. This study evaluates the efficacy of the blocking screw technique in preventing malalignment during intramedullary nailing. MATERIAL AND METHODS: In cases of subtrochanteric femoral fractures where malalignment, such as varus and anterior angulation, was anticipated during intramedullary nailing, proper reduction was ensured using blocking screw technique on the proximal bone fragment from the coronal or sagittal plane. A retrospective analysis was conducted on 25 patients (14 males, 11 females; average age 55.12 years) who were followed up for more than 1 year. The postoperative neck-shaft angle, anterior angulation angle, and limb length discrepancy were compared radiologically with those on the healthy side, and the presence and duration of bone union were measured. The Harris hip score was used for functional evaluation, and complications, including infection, were analyzed. RESULTS: At the final follow-up, primary bone union was achieved in 21/25 patients (84%), with an average bone union time of 21.81 weeks (range, 14-42 weeks). Of the four nonunions, bone union was achieved in three cases through bone grafting and supplemental plating and in the other case through intramedullary exchange, supplemental plating, and bone grafting. The femoral neck-shaft angle and anterior angulation showed no statistically significant differences compared with the healthy side, with averages of - 1.15° and - 1.4°, respectively. The limb length discrepancy was an average of - 2.4 mm. Regarding functional outcomes, the Harris hip score averaged 89.52 points (range 82-94 points). CONCLUSIONS: In subtrochanteric femoral fractures, the blocking screw technique effectively prevents malalignment during intramedullary nailing, ensuring not only appropriate reduction but also high bone union rates.

The role of fibula fixation in combined distal-third tibia and fibula fractures: a systematic literature review.

OBJECTIVE: The role of concomitant fibula fracture fixation in distal-third tibia fractures regarding alignment, union, and functional outcome is still a topic of debate. In this review, we summarize the available comparative literature regarding fibula fixation in distal third lower leg fractures. MATERIALS AND METHODS: A systematic literature review of articles published between January 2000 and January 2022 in the PubMed, Cochrane, and EMBASE databases about this topic was performed. RESULTS: 746 unique studies were identified of which four randomized-controlled trials and six retrospective studies were included. Nine studies compared alignment after tibia fixation with or without fibula fixation, six studies reported on tibial union, and three studies reported on functional outcome between groups. Pooling of data was not possible due to varying outcome measures and inclusion criteria. Fibula fixation was associated with less rotational malalignment, while there does not seem to be consensus regarding the effect on sagittal and coronal alignment. Six studies reported on the effect of fibula fixation on tibial union. None of these studies found a significant difference between treatment modalities. Furthermore, one out of three studies reporting functional outcome described a marginal beneficial functional outcome after fibula fixation. Ultimately, no differences in complication rates between treatment modalities were described. CONCLUSION: Fixation of the fibula in distal-third lower leg fractures does not seem to have a significant effect on coronal and sagittal tibial alignment. Furthermore, fibula fixation is associated with significantly less rotational malalignment, although the clinical importance of this finding is questionable as true differences in rotational alignment between treatment modalities are small. Finally, fibula fixation does not affect union, functional outcome, or complication rate as adjuvant to tibia fixation. LEVEL OF EVIDENCE: II.

Ilizarov fixator as salvage procedure after frustrating arthrodesis using intramedullary nailing - is there a chance of consolidation?

INTRODUCTION: Arthrodesis of the tibiotalar and subtalar joints is a salvage procedure that has been used successfully for years. Treatment options include internal procedures and external procedures. Retrograde intramedullary nailing is considered a safe procedure with a high degree of stability and comfort. Nevertheless, there are cases in which this internal arthrodesis fails and another procedure must be considered. Ilizarov fixator treatment could be a solution for those patients in whom intramedullary nailing has failed. Even if it means another surgical revision - is it possible to finally achieve consolidation with this method? MATERIALS AND METHODS: In this single-center, retrospective study all documents of patients who underwent tibiotalar and subtalar joints fusion using the Ilizarov external fixator at our institution from 2003 to 2023 as secondary treatment after frustrated first arthrodesis using an intramedullary nail were reviewed. Nineteen patients (17 men and 2 women), with an average age of 55.7 (standard deviation (SD) 8.7, range 34-75) years were included. RESULTS: On average, 1.7 (SD 1.3, range 1-6) arthrodesis attempt were performed before final Ilizarov fixator arthrodesis. The average time spent in the Ilizarov fixator was 19 (SD 4, range 14-29) weeks. In seven cases (36.8%), both the tibiotalar and subtalar joints received bony consolidation in the end. CONCLUSION: If patients have undergone fusion of the tibiotalar and subtalar joints with a retrograde nail and this fails, it is difficult to achieve complete consolidation in the further course. A further attempt at arthrodesis using an Ilizarov fixator is possible, but the overall results are also poor. This procedure must therefore be seen as a last resort before amputation.

Failure after intramedullary nailing for geriatric trochanteric fracture: does quality of fracture reduction on the AP and lateral planes show the same results?

PURPOSE: This study aimed to investigate the failure of trochanteric fracture fixation according to the quality of fracture reduction on the anteroposterior (AP) and lateral views. METHODS: Data from 340 female and 152 male patients ≥ 60 years of age who underwent intramedullary nailing for a trochanteric fracture between 2016 and 2020 were analysed retrospectively. The quality of fracture reduction was classified as type A, type E, and type I on the AP view and type N, type A, and type P on the lateral view according to the relative position of the proximal and distal fragments. The failure rate was evaluated and compared according to the quality of fracture reduction. The risk factors of the fixation failure were investigated by comparison of variables between patients with and without failure and by regression analysis. RESULTS: Patients with poor reduction, type I and type P had higher failure rates. However, a statistically significant difference was found only for patients with poor reduction (type P) on the lateral view (p < 0.001). Patients with failure showed significantly higher rates of poor reduction on the lateral view and AO/OTA type A3 fractures. The regression analysis also showed that poor reduction on the lateral view (odds ratio [OR] 12.70; 95% confidence interval [CI] 4.0-40.6; p < 0.001) and AO/OTA type A3 fractures (OR 5.40; 95% CI 1.24-23.49, p = 0.025) were risk factors for failure. CONCLUSION: Poor reduction such as type P reduction was associated with failure after intramedullary nailing for trochanteric fractures. Surgeons should check the quality of fracture reduction carefully with the proper fluoroscopic view to prevent failure in geriatric patients with trochanteric fractures.

Comparative study of retrograde intramedullary nailing versus locking extramedullary plating in complete articular fractures with metaphyseal comminution of the distal femur.

INTRODUCTION: Fractures of the distal femur with metaphyseal comminution and complete intra-articular involvement (AO/OTA classifications 33C2 and 33C3) present challenges for reduction and fixation. However, an optimal fixation method remains unknown. This study aimed to compare the clinical and radiographic outcomes of locking extramedullary plating (LEP) and retrograde intramedullary nailing (RIN) for complete distal femoral intra-articular fractures with metaphyseal comminution. MATERIALS AND METHODS: Between January 2016 and May 2022, 80 patients (45 men and 35 women; average age, 56.7 years) diagnosed with AO/OTA 33C2 and 33C3 were treated with either LEP or RIN and followed up for at least one year. Post-operative evaluations included radiographic assessments of bone union rate, timing, and alignment. Clinically, the knee joint range of motion (ROM), lower extremity functional scale (LEFS), and Kellgren and Lawrence (KL) grade were analyzed. The complications were also compared. RESULTS: 36 underwent LEP and 44 underwent RIN. Bone union was observed in 69.4% and 63.6% of the patients in the LEP and RIN groups, respectively (p = 0.64). The average union time was 6.9 months for the LEP group and 6.6 months for the RIN group (p = 0.51). A tendency toward varus deformity was observed in the RIN group, although the difference was not statistically significant. No significant differences were observed in knee ROM, LEFS, or KL grade. Complications included non-union (33.8%; RIN, 11; LEP, 16), varus deformity (5%; RIN, 4; LEP, 0), infection (1.3%; RIN, 0; LEP, 1), heterotrophic ossification (1.3%; RIN, 0; LEP, 1), and wound dehiscence (2.5%; RIN, 2; LEP, 0). CONCLUSIONS: The surgical fixation methods, RIN and LEP, for complete distal femoral intra-articular fractures with metaphyseal comminution showed similar clinical and radiological outcomes. However, regardless of the type of fixation device used, there was a reduced rate of bone union owing to high energy and a less favorable prognosis.

Comparing outcomes of plate augmentation, nail exchange, and nail exchange with plate augmentation in the treatment of atrophic femoral shaft nonunion after intramedullary nailing: a multicenter retrospective study.

INTRODUCTION: Intramedullary (IM) nailing is the treatment of choice for femoral shaft fractures, but nonunion rates have been reported to be as high as 12%. Surgical interventions for nonunion involve exchange nailing or plate augmentation. Recently, a combined treatment of exchange nailing and plate augmentation has demonstrated good results, but its comparative effectiveness remains unclear. This study aimed to compare the clinical and radiographic outcomes of three different surgical interventions for atrophic femoral shaft nonunion, and investigate the factors that affect bone healing after reoperation. MATERIALS AND METHODS: A retrospective study was conducted at five university hospitals involving 149 patients with aseptic atrophic nonunion after IM nailing. These patients underwent reoperation with plate augmentation, exchange nailing, or combined treatment. Clinical and radiographic outcomes were assessed and compared according to reoperation procedure. Logistic regression analysis was performed to identify factors affecting persistent nonunion after reoperation. RESULTS: Of the cohort, 57 patients underwent plate augmentation, 64 underwent exchange nailing, and 28 received combined treatment. There were no significant differences in patient demographics among the groups. Exchange nailing produced a significantly lower union rate than did the combined treatment (82.8% vs. 100%, p = 0.016), whereas no significant difference was observed in the union rate and time to the union between plate augmentation and the combined treatment. Combined treatment showed the longest operative time and the greatest transfusion requirements. The risk factors for persistent nonunion included age, absence of autogenous bone grafts, and use of an exchange nailing technique. CONCLUSIONS: Exchange nailing as a treatment for atrophic femoral shaft nonunion after IM nailing resulted in a lower union rate. The efficacy of the combined treatment requires further study, and persistent nonunion may be influenced by age, bone grafting, and surgical techniques. A comprehensive approach targeting both biological environment and mechanical stability is crucial in the treatment of atrophic femoral shaft nonunion.

Mechanical Complications of Proximal Femur Fractures Treated with Intramedullary Nailing: A Retrospective Study.

Background and Objectives: This retrospective cohort study analyzes mechanical complications in hip fracture surgery using the Trochanteric Fixation Nail-Advanced (TFNA) implant. It investigates the correlation of these complications with demographic, intraoperative, and radiological factors, aiming to identify associated risk factors and suggest improvements in clinical surveillance and treatment strategies. Materials and Methods: We enrolled 253 patients diagnosed with pertrochanteric hip fractures treated between 2017 and 2021, with 126 meeting the criteria for a minimum 6-month follow-up. Data on demographics, American Anesthesia Association Classification (ASA), comorbidities, AO/OTA [AO (Arbeitsgemeinschaft für Osteosynthesefragen)/OTA (Orthopedic Trauma Association)] fracture classification, procedural details, and time to failure were collected. Radiographs were evaluated for reduction quality, the tip-apex distance (TAD), progressive varus deviation, and identification of mechanical complications. Statistical analysis was performed using SPSS software. Results: The predominant AO/OTA fracture classification was 31A2 in 67 cases (52.7%). Reduction quality was deemed good or acceptable in 123 cases (97.6%). The mean time to failure was 4.5 months (range: 2.2-6). The average TAD was 18 mm (range: 1.2-36), with a mean progressive varus deviation of 2.44° (range: 1.30-4.14). A good or acceptable reduction quality was observed in 97.6% of cases. Mechanical complications occurred in 21.4% of patients, with significant associations found with the lateral cortex fracture, use of a TFNA implant with a 130° angle, open reduction, and absence of prior osteoporosis treatment. Conclusions: The study provides insights into mechanical complications in proximal femur fractures treated with the TFNA nail, emphasizing the need for enhanced clinical and radiographic surveillance, especially in patients without osteoporosis treatment. Our findings support the necessity for further clinical studies comparing these outcomes with other implant designs and underscore the importance of personalized treatment strategies to reduce complication rates.

Tibiotalocalcaneal nail and primary closure for the management of open ankle fractures in the elderly patient; results from a major trauma centre.

INTRODUCTION: Open ankle fractures in elderly patients are challenging injuries to manage. The aim of this study was to assess the outcome of elderly patients with open ankle fractures treated with a tibiotalocalcaneal nail and primary wound closure. METHODS: We identified all open ankle fractures in patients over 65 referred to our major trauma centre managed with a tibiotalocalcaneal nail and primary wound closure over 10 years. We recorded patient demographics, comorbidities, injury mechanism, length of stay, operation, weightbearing status, re-operations, infections and mortality. RESULTS: We included 34 patients with an average age of 87 (73-99). We found 56 % of patients' mobility status declined post-operatively and 21 % of patients were discharged directly home. Four patients required further unplanned surgery including two deep infections requiring amputation. We had a 6 % three month mortality rate. CONCLUSION: Use of a tibiotalocalcaneal nail with primary wound closure offers a reasonable treatment option for open fractures of the ankle in the elderly patient.

An age-matched comparative study on intramedullary nailing and plate fixation of both-bone diaphyseal forearm fracture in adolescents.

OBJECTIVE: This study aimed to compare radiological and functional outcomes and complication rates between intramedullary nailing (IMN) and plate fixation for diaphyseal forearm fractures in adolescents via an age-matched analysis. METHODS: Data were collected from medical records at 11 hospitals from 2009 to 2019, and the age-matched study was conducted between IMN and plate fixation. Functional outcomes, radiographic outcomes, and postoperative complication rates were compared. RESULTS: The IMN group (Group N) and plate fixation group (Group P) each comprised 26 patients after age matching. The mean age after matching was 13.42 years old. Bone maturities at the wrist of the radius and ulna were not significantly different between the two groups (p = 0.764 and p = 1). At the last follow-up period, functional outcomes using the Price criteria were over 90% in both groups, and the rotational range of motion was comparable to that of the healthy side. Over 70% of cases in Group N were performed by closed reduction, and operation time was half that of Group P. Postoperative neurological symptoms and refractures were more common in Group P than in Group N, although not statistically significantly so. CONCLUSIONS: Treatment outcomes for age-matched adolescent diaphyseal forearm fractures were excellent with IMN, as well as with plate fixation in many cases despite fewer complications, better cosmesis, and shorter operative times with IMN. IMN for diaphyseal forearm fractures is a useful treatment option even in adolescents although the indications for the best procedure to perform should be considered depending on individual patient needs. LEVEL OF EVIDENCE IV: Multicenter retrospective study.

Plating as a reduction aid prior to intramedullary nailing of tibia fractures: a systematic review and meta-analysis.

PURPOSE: The purpose of this meta-analysis is to analyse the literature on plate-assisted reduction during intramedullary nailing of tibial shaft fractures and to compare the rates of infection and nonunion. METHODS: The databases Medline, Embase, and Web of Science were searched from inception to February 2022 for literature comparing plate-assisted reduction during intramedullary nailing of extra-articular tibia fractures to standard, closed means of reduction. Data were extracted and pooled in a random effects meta-analysis for the primary outcomes of nonunion and infection risk. RESULTS: Five comparative studies were identified including 520 total patients, of which 151 underwent tibial nailing with the use of plate-assisted reduction with an average follow-up time of 17.9 months. Approximately two-thirds of patients retained the plate used to assist reduction during intramedullary nailing (102 of 151). Pooled analysis of the infection rates found no significant difference with plate-assisted intramedullary nailing (Risk Ratio [RR] 0.90, 95% CI 0.49-1.65, p = 0.72), and for nonunion rates, there was also no significant difference with plate-assisted intramedullary nailing (Risk Ratio [RR] 0.80, 95% CI 0.40-1.60, p = 0.53). CONCLUSIONS: Plate-assisted reduction during intramedullary nailing of tibia shaft fractures was not associated with an increased risk for nonunion or infection, and can be safely applied as an adjunct for reduction in challenging fracture patterns, without the need for later removal. However, evidence is quite limited and further investigation into the use of provisional plating as a technique is needed as its use in intramedullary nailing continues to expand.