Non-Vascularized Fibular Cortical Strut Graft with Intramedullary Nailing for Fibrous Dysplasia of the Proximal Radius - A Case Report.

Introduction: Fibrous dysplasia (FD) is a skeletal developmental abnormality commonly affecting the ribs, femur, tibia, skull, pelvis, spine, and shoulder. FD of the proximal radius is extremely rare and very few cases have been reported. In addition, monostotic lesions of FD in the upper extremity go unnoticed as they are usually asymptomatic. Symptomatic lesions warrant surgical intervention. Here, we present a rare case of FD of the proximal radius treated with curettage and non-vascularized fibular cortical strut graft with intramedullary elastic nailing. We believe that this is the first report in the literature wherein this treatment modality has been undertaken. Case Report: A 27-year-old woman presented with excruciating pain and swelling in her right elbow for 4 weeks, with no inciting event or trauma leading to the pain. Plain radiographs revealed a well-circumscribed radiolucent lesion in the proximal radius with cortical thinning at the metaphysis and a rim of epiphyseal bone. Clinically, the patient had restricted supination (50°) and limited elbow range of motion (ROM) (20-130°), mostly because of the pain but had full pronation. With these radiographic and clinical features, FD and giant cell tumor were kept as differential diagnoses and surgical treatment was planned. The lesion was excised leaving the normal epiphysis of the radius intact and samples were sent for histopathological examination. A non-vascularized fibular cortical strut graft was harvested from the same side and was fluted into the radial shaft. Final stabilization was done using a 2.5 mm intramedullary elastic nail. The arm was immobilized in an above-elbow slab. Histopathology confirmed our diagnosis of FD. The slab was removed after 6 weeks, and a gentle ROM was started in the form of active-assisted ROM. At the end of 1 year, complete union and almost full ROM were achieved and the patient was completely pain-free. Conclusion: Non-vascularized fibular strut grafting with intramedullary nailing provides a comparatively quicker, cost-effective way of treating this lesion with a minimum insult of the bony cortex and quicker rehabilitation.

A Comparative Study of the Early Postoperative Outcome of Three Intramedullary Fixation Modalities in the Treatment of Intertrochanteric Fractures of the Femur in the Elderly.

OBJECTIVES: To compare early outcomes of proximal femoral bionic nail (PFBN), Inter-TAN, proximal femoral nail antirotation (PFNA) for intertrochanteric fractures in elderly patients. METHODS: Eighty-two elderly patients with intertrochanteric femoral fractures treated at Xiangyang No. 1 People's Hospital affiliated with Hubei University of Medicine from December 2021 to 2022 were retrospectively analyzed. They were categorized into three surgical groups: PFBN (22 cases), Inter-TAN (20 cases), and PFNA (40 cases). Preoperative demographics and fracture characteristics were compared, alongside intraoperative and postoperative metrics like operative time and complication rates. RESULTS: In the PFBN group, operative time, fluoroscopy use, blood loss, and transfusion were higher, but postoperative weight-bearing, healing, and hospital stay were shorter compared to the Inter-TAN and PFNA groups (P<0.05). Inter-TAN had a significantly shorter postoperative weight-bearing time than PFNA (P<0.001). Other compared factors showed no significant differences between groups (P>0.05), including complication rates and scores at 6-month follow-up. CONCLUSIONS: PFBN, a novel surgical approach for intertrochanteric fractures in elderly patients, outperforms Inter-TAN and PFNA by accelerating early weight-bearing and hastening fracture recovery.

Treatment Outcomes of Dynamic Hip Screws Versus Short Intramedullary Nails for Extra-capsular Fragility Hip Fractures and Their Coding Audit.

Introduction In the UK, hip fractures are a common reason for presentations to the emergency departments, which places significant pressure on NHS hospitals, appropriate choice of an implant to treat the hip fracture is one among many other factors that affect patients' outcomes. This audit aims to identify and compare the outcome difference between the dynamic hip screws (DHS) and short cephalomedullary nails in the treatment of extracapsular hip fractures. Methods In a retrospective study of 52 patients admitted as a result of hip fractures in one NHS trust, data collection was done from the patients' records using the trust's online system, we studied different variables to compare the outcome difference between DHS and short intramedullary (IM) nails, two senior authors interpreted the patients' X-rays and verified the coding and classification of the neck of femur fractures. Results This retrospective study examined 52 extracapsular hip fracture cases, including 37 females and 15 males. Forty-six (88%) of the included patients were ASA 3 and 4 (American Society of Anesthesiologists), and the average days to discharge from therapies were 8.4 (SD-+ 4) days compared to 11 (SD-+ 5.2) days for short IM nails and DHS, respectively (P= 0.03), the 30-day mortality rate for short nails was 7% (n= 4/52) patients and 6% (n= 3/52) for DHS (P =0.69). The mean operating times for the different implants were 58.11 (SD-+ 15.1) minutes for DHS and 58.03 (SD-+ 23.2) minutes for the short nail (P =0.98). Compliance with the national guidelines for providing an appropriate operation to treat hip fractures initially went from 63% (n=33/52) initially to 73% (n=38/52). This means that more patients who are appropriate for nailing are being treated with IM nails. Conclusion Short IM nails are associated with faster hospital discharge; this fact may be reflecting the lower postoperative pain as a result of avoiding soft tissue dissection associated with extramedullary devices. keeping in mind that IM devices have mechanical advantages over sliding hip screws; hence, they are more commonly used for more complex fracture patterns, leading to nearly similar outcomes when compared to extramedullary devices, this can be a source of bias in retrospective studies, larger randomized trials may lead to different outcomes.

Comparison of estimated glomerular filtration rate using five equations to predict acute kidney injury following hip fracture surgery.

BACKGROUND: Decreased estimated glomerular filtration rate (eGFR) is associated with acute kidney injury (AKI) following hip fracture surgery. Delaying surgery for preoperative treatment of comorbidities is controversial in this patient population. The purpose of this study was 1) to assess differences in demographics and comorbidities between AKI and non-AKI groups, 2) to analyze equations used in calculating eGFR, and 3) to identify the equation which best predicts the development of AKI following hip fracture surgery. We hypothesize that one of the equations used to calculate eGFR will be superior to the others. PATIENTS AND METHODS: 124,002 cases of hip fracture surgery were performed from 2012 to 2019, based upon a query of the National Surgical Quality Improvement Program (NSQIP). Preoperative eGFR was calculated using the following: Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Chronic Kidney Disease Epidemiology Collaboration, Mayo quadratic, and Cockcroft-Gault equations. Independent associations between preoperative eGFR and postoperative renal failure were evaluated using multivariate regression analysis. The predictive ability of each equation was determined using the Akaike information criterion (AIC). RESULTS: AKI was diagnosed in 584 (0.71%) out of the 82,326 patients following hip fracture surgery. The AKI and no AKI cohorts differed significantly by patient sex (p = <0.001), race (p = <0.001), BMI (p = < 0.001), preoperative hematocrit (p = <0.001), preoperative albumin (p = <0.001), diabetes mellitus (p = <0.001), hypertension (p = <0.001), and congestive heart failure (p = <0.001). The Mayo equation (84.0 ± 23.7) was the equation with the highest calculated mean eGFR, followed by the CKD-EPI equation (83.6 ± 20.0), MDRD II equation (83.0 ± 38.9), CG equation (74.7 ± 35.5), and finally the re-expressed MDRD II equation (68.5 ± 36.0) which had the lowest calculated mean eGFR.. All five equations detected that a decrease in preoperative eGFR was associated with an increased risk of postoperative AKI. Lower preoperative eGFR, as calculated by each of the five equations, was significantly associated with an increased risk of AKI following surgical fixation of hip fracture. The AIC was the lowest in the Mayo equation, demonstrating the best fit of the equations to predict postoperative AKI CONCLUSIONS: We propose that using the equation that best identifies those at risk of developing postoperative AKI may help with perioperative decision making and treatment to improve outcomes, which we found to be the Mayo equation. The risk of postoperative AKI was independently associated with decreased preoperative eGFR. The results of this study may warrant further investigation utilizing prospective studies. LEVEL OF EVIDENCE: III; retrospective cohort study.

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

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

Angle Accuracy of Intramedullary Bone Resection Guides for Total Knee Arthroplasty.

The importance of proper prosthetic placement has been confirmed in numerous studies. The objective of this study was to compare the planned resection angles to the verified intraoperative angles of femoral and tibial varus/valgus, tibial slope, and femoral flexion for each total knee performed using intramedullary (IM) cut guides for both distal femur and proximal tibia cuts. A total of 1,000 total knee arthroplasties (TKAs) were evaluated for this study. Intraoperative cut-check technology was used to show real-time validation of these resection angles. Assuming an acceptable range of within 2° of the planned cuts, results show the femoral varus/valgus angles were 75% accurate, the femoral flexion angles were 50.8% accurate, the tibial cuts were 95.2% accurate in the coronal plane, and the tibial slope was the least accurate with only 50.3% within the acceptable range. This showed that IM guides are reasonably accurate in producing desired angles in the coronal plane but less accurate in the sagittal plane, with a greater number of outliers in femoral flexion and posterior slope. Surgeons need to be aware of potential cutting errors when using IM guides as they affect the overall alignment of the implant, and real-time verification technology is available to verify the accuracy of the cuts.

Long-term survival following molecular-targeted therapy for intramedullary non-small-cell lung cancer metastasis.

Background: Intramedullary spinal cord metastases (ICSMs) are very rarely curable; these patients typically have very short-term survival rates. Here, a 22-year-old male with non-small-cell lung cancer (NSCLC) later developed ICSM twice; the first C4-C7 tumor responded well to surgery, radiation, and alectinib molecular-targeted therapy. The secondary ICSM C1 lesion seen years later (i.e., likely due to alectinib having been stopped) resolved once alectinib was again administered. Case Description: A 22-year-old male with a limited smoking history presented with advanced non-small-cell lung cancer (NSCLC) treated with pulmonary surgery followed by radiotherapy and chemotherapy. Four years later, he developed cervical myelopathy attributed to a C4-C7 stage IV NSCLC ICSM (i.e., notably associated with an anaplastic lymphoma kinase [ALK] rearrangement). After cervical surgery and irradiation (40 Gy/20 fr) of the resection cavity, he was also given alectinib; the patient remained disease-free for the next 7 years, remaining on alectinib. However, 1 year after alectinib was discontinued, he experienced a newly occurrent C1 ICSM lesion; the alectinib was restarted, and his tumor regressed over the next 3 years. At present, 14 years after the original ICSM surgery, the patient remains disease free but continued alectinib (Karnofsky Performance Scale: 90%). Conclusion: Although the prognosis for ICSM is generally poor, molecular-targeted therapies, such as alectinib, as administered in this case, may provide long-term survival for patients with ALK-positive NSCLC tumors.

Minimally invasive tubular approach to intramedullary cavernous malformations.

Background: Advancements in minimally invasive spinal surgery have led to an expansion of targeted pathologies as well as improvements in surgical outcomes compared to their conventional counterparts through open laminectomy; however, this technique is rarely mentioned in the literature for intrinsic cord lesions. The authors present a novel minimally invasive, dorsolateral, and expandable tubular approach for the resection of an intradural, intramedullary thoracic cavernous malformation (CM). Case Descriptions: A 52-year-old male patient presented with rapidly progressive myelopathy and loss of ambulatory capabilities, with which magnetic resonance imaging revealed a hemorrhagic CM within the thoracic spinal cord. The CM was successfully resected through a minimally invasive tubular approach utilizing a dorsal root entry zone myelotomy. Postoperative imaging confirmed gross resection. His motor examination rapidly recovered, and he remains ambulatory with the use of a cane at a 2-year follow-up. Conclusion: This novel minimally invasive approach is a promising technique for well-selected cases of symptomatic spinal CMs. Further exploration and potentially randomized studies are necessary to fully affirm the tubular approach's suitability for the treatment of intradural intramedullary CMs compared to conventional techniques.

Forward-striking technique in simple femoral shaft fractures: a comparative cohort study.

BACKGROUND: A persistent fracture gap following femoral nailing increases the risk of delayed and nonunion development. A forward-striking technique for reducing the gap in femoral nailing has been described, but its efficacy and therapeutic consequences have not been investigated in comparative studies. We provide the results of a comparative study that investigated the forward-striking technique's efficacy in terms of remaining fracture gaps and surgical outcomes. METHODS: Between 2017 and 2022, a retrospective cohort study was undertaken on 193 skeletal mature patients obtaining reamed femoral nailing for closed femoral shaft fractures. Comparisons of residual fracture gaps, timing to union, complications and re-operation rates were made between 80 patients (41.45%) undergoing femoral nailing with the forward striking procedure and 113 patients (58.55%) undergoing traditional nailing, accompanied by minimal 1-year follow-ups. In addition, the potential difference between fracture gaps before and after applying the forward striking procedure was compared. RESULTS: Both groups had similar age, sex, presence of diabetes, smoking status, body mass index and time to surgery. However, the forward-striking group demonstrated significantly lower rates of postoperative complications, including delayed, nonunion, and the need for re-operation. Conversely, no significant differences were found in time to union (p = 0.222). The forward-striking procedure can significantly reduce residual fracture gaps from 3.99 to 1.66 mm (p < 0.001). No major complications in the forward-striking group including nonunion were observed. CONCLUSION: This study suggests that the forward-striking technique effectively reduces residual fracture gap during femoral nailing. The technique not only could be easily performed but is also reproducible. In addition, it can lower the risk of delayed union, nonunion and obviates the necessity for re-operation. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Treatment of Infected Tibia Non-union Using a Novel Solid Intramedullary Nail Custom-Made for Antibiotic-Impregnated Cement Coating.

The chronic and incapacitating condition of infected non-union of the long bones continues to be a challenging issue for surgeons in terms of efficient and economical treatment. A number of variables, such as open fractures, soft tissue or bone loss, infection following internal fixation, persistent osteomyelitis with pathologic fractures, and surgical debridement of infected bone, can result in infected non-unions. An infected non-union is typically treated in two stages. To transform an infected non-union into an aseptic non-union, the initial step involves debridement, either with or without the insertion of antibiotic cement beads and systemic antibiotics. In order to ensure stability, external or internal fixation - with or without bone grafting - is carried out in the second stage. There is a wealth of literature supporting the use of antibiotic-impregnated cement-coated intramedullary (IM) nailing for infected non-union of tibia and femur fractures. In contrast to cement beads, the cement nail offers stability throughout the fracture site, and osseous stability is crucial for the treatment of an infected non-union. When using antibiotics for this purpose, they should possess unique qualities, including low allergenicity, heat stability, and a broad spectrum of activity. The most commonly utilised medication has been gentamicin, which is followed by vancomycin. Furthermore, it has been discovered that solid nails are more resistant to local infection than cannulated IM nails. In this case study, the patient was treated with a solid IM nail that had a specially designed slot on its exterior surface for the application of cement impregnated with antibiotics. In conclusion, an easy, affordable, and successful treatment for infected non-union of the tibia is antibiotic cement-impregnated nailing. It has strong patient compliance and removes the problems associated with external fixators, which makes it superior to them. A few benefits of this approach are early weight-bearing, stabilisation of the fracture, local antibiotic treatment, and the potential for accelerated rehabilitation. Additionally, lowering the requirement for continuous antibiotic medication may lessen the chance that antibiotic resistance may arise.

Biomechanical difference analysis of new and classic intramedullary nail devices in the treatment of basal femoral neck fractures: finite element analysis.

OBJECTIVE: There is currently a lack of in-depth comparative evaluation regarding the biomechanical properties of novel intramedullary nail devices in the treatment of basal femoral neck fractures (BFNF). This study aims to utilize finite element analysis to compare the performance differences of two novel devices with traditional PFNA and InterTan nails in the fixation of BFNF. METHODS: Based on a validated finite element model, this study constructed an accurate BFNF model and implanted four different intramedullary nail devices: PFNA, InterTan nail, PFBN (proximal femoral biomimetic nail), and NIS (novel intramedullary system). Under a vertical load of 2100N, the displacement and Von Mises stress (VMS) distribution of each group of models were evaluated through simulation testing. RESULTS: Under a load of 2100N, the PFBN device exhibited the best performance in terms of displacement and peak stress, while PFNA performed poorly. The peak displacement of the NIS device was lower than that of PFNA and InterTan nails, while the peak stress of the InterTan nail was lower than that of PFNA and NIS. CONCLUSION: The PFBN device demonstrates stronger load-bearing and shear-resistant properties in the treatment of BFNF, and the NIS device also shows significant improvement in stability. Therefore, both the PFBN and NIS devices are reliable internal fixation techniques for the treatment of CFIFs, with potential clinical application prospects.

Induced membrane technique and intramedullary beaming for the extensive bone defect of the talonavicular joint: A case report and literature review.

Cases involving both the induced membrane technique (IMT) and intramedullary beaming (IB) are generally rare. Here, we report such a case in an 83-year-old man who presented with left midfoot pain. Pyogenic arthritis was suspected based on clinical findings, and curettage was performed, revealing an extensive bone defect. The patient was clinically diagnosed with seronegative rheumatoid arthritis (RA). Therefore, the patient underwent both IMT and IB for the extensive bone defect in the talus and navicular regions caused by seronegative RA. The patient exhibited satisfactory short-term outcomes.

Intramedullary versus locking plate fixation for proximal humerus fractures: indications and technical considerations.

Background: The incidence of proximal humerus fractures (PHFs) continues to increase with an aging population, and intramedullary nailing (IMN) and locking plate fixation are two commonly employed techniques for the surgical management of PHF. However, the optimal fixation method can be a source of ongoing controversy. Some influencing factors include the extent of humeral head involvement, fracture complexity, patient age, and surgeon preference. There are many studies that provide a mix of data either when comparing the two techniques or analyzing them in isolation. The aim of this review is to further elucidate the indications and technical considerations involved specifically in IMN vs. locking plate fixation for PHF to further aid orthopedic surgeons when choosing surgical management. Methods: A narrative approach was chosen for this review allowing for a comprehensive review of literature, including recent findings pertaining to the comparison of management options for PHF. A comprehensive literature search was conducted using the PubMed, Embase, and Cochrane Library databases. The inclusion criteria involved studies that discussed "proximal humerus fracture" and either "intramedullary nail" or "locking plate fixation." Results: Complications such as avascular necrosis, hardware failure, additional surgical interventions, infection, fracture redisplacement, rotator cuff rupture, and nonunion did not show significant differences between the two groups. Newer generation humeral nails have minimized early complications. As both techniques undergo further refinement and utilization when specifically indicated, functional outcomes, potential complications, and postoperative pain continue to be improved. Conclusion: The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method. The choice of technique should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations. Surgeon experience also plays a role. While certain presentations may exhibit trends that favor one fixation, no specific technique can be universally recommended. Both IMN and LP have shown comparable and satisfactory outcomes, and the final fixation method chosen should take into account the unique characteristics of each patient.

Clinical presentation and magnetic resonance imaging findings of a spinal cord ganglioglioma in a 7.5-year-old, male, neutered German shepherd dog.

A dog presented with a 1-month history of left-sided hemiparesis. MRI showed a focal, 4-cm-long, symmetrical, ovoid, poorly demarcated intramedullary expansion at C6-C7 that was T2-weighted hyperintense, T1-weighted isointense, and noncontrast enhancing. After clinical progression and euthanasia, pathology revealed a neoplasm composed of astrocytes and dysmorphic neurons, consistent with a ganglioglioma. The diagnosis was confirmed with immunohistochemistry and transmission electron microscopy, which demonstrated electron-dense granules in the perikaryon. Gangliogliomas are rare, benign neoplasms that may present as intramedullary spinal cord neoplasia. This is the first report on the clinical presentation, imaging, and pathology of a canine spinal ganglioglioma.

Effect of bone grafting on bone union in exchange nailing for the treatment of femoral shaft nonunions.

OBJECTIVE: This study aims to investigate the effect of bone grafting on the bone union in exchange nailing (EN) for the treatment of femoral shaft nonunions. METHODS: A total of 26 patients (16 male) were included in this study. The mean age of the patients was 36.1±9.3. Bone grafts were used in 8 patients (bone graft group), and EN was performed without bone grafting (no bone graft group) in 18 patients. Etiology, fracture type, location, and classification of the fractures at the time of initial injury were evaluated. The reduction type (open or closed) and locking status of the nails were also noted. Nonunion types were recorded. In the bone grafting group, iliac bone autografts were used in seven patients and a synthetic bone graft was used in one patient. Following EN, the presence and duration of bone union, and the increase in the nails' diameter were analyzed for each group and compared. RESULTS: Union rates were 100% and 94.4% in bone grafting and no bone grafting groups, respectively. The mean union period was not significant between the groups (22.5 and 16.5 months, respectively). The mean increase in the nail diameter was 1.88 mm in the bone graft group and 2.00 mm in the no bone graft group (p>0.05). CONCLUSION: This study demonstrated that high union rates can be achieved with EN by means of using larger diameter nails with or without bone grafting in the management of femoral shaft nonunions, and bone grafting had no significant effect on union rates and periods.

Intramedullary Nail Fixation for Metacarpal Fracture: A Case Report and Review of the Clinical and Biomechanical Evidence.

We present two cases of complex metacarpal fractures treated with an intramedullary locking nail. This is an emerging fixation method that minimizes tissue insult, provides sufficient stability, and allows early mobilization. Locking nails accommodate the capture of fractured fragments in complex unstable patterns and provide longitudinal and rotational stability. The described intrafocal technique is intended to improve coaxial placement of the wire into the medullary canal.

[Stereotactic high-dose irradiation for intramedullary metastases]. / Stereotaksicheskoe vysokodoznoe obluchenie v lechenii intramedullyarnykh metastazov.

Intramedullary metastases (IMM) lead to severe neurological symptoms. They are extremely rare in clinical practice. Optimal management of such patients is not clearly defined. Surgery, chemo- and radiotherapy are the main options. OBJECTIVE: To study the results of stereotactic high-dose irradiation for IMM considering local control of metastases, neurological status and life expectancy. MATERIAL AND METHODS: Nineteen patients with 29 IMMs underwent high-dose irradiation (Cyber Knife G4 and TrueBeam STx devices) between 2016 and 2022. There were 1-10 fractions, radiation dose 14.0-35.0 Gy with isodose 70-100%. Local control and new spinal cord metastases were assessed using contrast-enhanced MRI. Clinical status and neurological functions were assessed using the Karnofsky and McCormick scales. RESULTS: Local control rates were 91% and 78% after 6 and 12 months, respectively. Overall survival after treatment was 7.3 months, 6- and 12-month overall survival - 58% and 37%, respectively. In addition, 8 patients were available for follow-up. Of these, 6 ones demonstrated improvement or stabilization of neurological function after treatment. The main cause of death was progression of the underlying disease. No significant treatment-related toxic effects were observed. CONCLUSION: High-dose irradiation is a safe, effective and time-saving treatment for IMM. Considering unadvisable surgical methods and chemotherapy for this pathology, we can recommend high-dose irradiation for patients with spinal cord metastases.

Does the Nonunion Rate of Atypical Femoral Fractures Differ According to Fracture Site?: A Meta-Analysis.

Background: The nonunion rate for atypical femoral fractures (AFF) is known to be higher than that for typical fractures of the femur. We performed a meta-analysis to determine the incidence of nonunion necessitating reoperation following fixation for AFF and compare the rates according to the fracture site (subtrochanter or midshaft). Methods: A total of 742 AFFs from 29 studies were included. A proportion meta-analysis utilizing a random-effects model was conducted to estimate the prevalence of nonunion. The outcomes were the incidence of reoperations that included osteosynthesis. To determine the association of nonunion with patient mean age or average duration of bisphosphonate use, meta-regression analysis was done. Results: In proportion meta-analysis, the estimated pooled prevalence of nonunion was 7% (95% confidence interval [CI], 5%-10%) from all studies. There was a significant difference in nonunion rate between the 2 groups (I2 = 34.4%, p = 0.02); the estimated prevalence of nonunion was 15% (95% CI, 10%-20%) in subtrochanteric AFFs and 4% (95% CI, 2%-6%) in midshaft AFFs. From meta-regression analysis, significant correlations were identified between nonunion rate and patient mean age (coefficient: -0.0071, p = 0.010), but not in the average duration of bisphosphonate use (coefficient: -0.0024, p = 0.744). Conclusions: A notable disparity existed in the nonunion rate among subtrochanteric AFFs and midshaft AFFs group. Therefore, it is critical for orthopedic surgeons to consider the complexity and challenges associated with AFF and to estimate the proper possibility of nonunion according to the fracture site.

Challenges of perioperative pain control in opioid use disorder patients following intramedullary nail fixation.

BACKGROUND: Outcomes of patients with opioid use disorder undergoing elective procedures have been well studied, but research is lacking in the orthopaedic trauma population. AIM: The aim was to compare perioperative pain and morphine equivalents required by patients with versus without opioid use disorder following intramedullary nail fixation of femoral or tibial fractures. METHODS: We conducted a retrospective review of all patients with isolated femoral or tibial diaphyseal fractures treated with intramedullary nail fixation. Outcomes were compared between patients with diagnosed opioid use disorder and controls without, including daily morphine equivalents and patient-reported pain scores. RESULTS: Patients with opioid use disorder (n = 42) required greater morphine equivalents and reported higher pain than controls (n = 42) at all time points but did not differ in change of morphine equivalents over the perioperative period. CONCLUSION: This highlights the challenge of perioperative pain control in this population and need for improved specific pain management protocols.