Clinical Outcome After Replacement of Distal Femur/Proximal Tibia in a Heterogeneous Patient Cohort: Function Following Tumour, Trauma, and Loosening.

BACKGROUND: Distal femur and proximal tibia replacements as limb-salvage procedures with good outcome parameters for patients with tumours have been broadly described. However, the overall midterm outcome in a mixed, heterogeneous patient collective is still unclear. PATIENTS AND METHODS: We retrospectively analysed 59 consecutive patients (33 for primary and 26 for revision surgery) between 1998 and 2017. Indication for implantation was tumour (n=16), periprosthetic fracture (n=14), traumatic fracture (n=14), infection (n=10), aseptic loosening (n=3), and pathological fracture (n=2). The mean follow-up duration was 3 years. Clinical functions were evaluated by Toronto Extremity Salvage Score and Knee Society Score. Knee extension and flexion force were measured. RESULTS: The overall survival rate of arthroplasties was 59% (n=35). Major complications were observed in 36 (61%) patients. During the follow-up period, 14 (24%) patients died. We recorded periprosthetic joint infection in 21 (36%) patients, recurrence of tumour in two (3%), and aseptic implant failure in three (5%). The mean Toronto Extremity Salvage Score was 66±33, and the mean Knee Society Score was 49±30. The mean extension force on the operated side was significantly reduced at 60° and 180° compared to the healthy side (p=0.0151 and p=0.0411, respectively). CONCLUSION: Distal femur and proximal tibia replacements showed limited clinical function in a heterogeneous patient collective. Indication for implantation should be considered carefully.

Reduction of Patella-baja and Pseudo-patella-baja Does Not Improve Range of Motion in Patients After Mega-TKA.

BACKGROUND/AIM: Patella baja (PB) and pseudo-patella baja (PPB) have been shown to negatively influence outcomes after total knee arthroplasty. We hypothesized that there is a high incidence of PB and PPB after megaprosthetic total knee arthroplasty (M-TKA), and that this is associated with reduced range of motion. PATIENTS AND METHODS: We retrospectively analysed all patients in our Orthopaedic Trauma Department after distal femur or proximal tibia replacement. Preoperative and one-year postoperative follow-up included measurement of range of motion and detection of PB and PPB using radiological indices. RESULTS: We included 44 patients (age: 73±19 years). Preoperative PB detected by ISI could be reduced from 13 (36%) to 11 (25%) (p<0.01). Preoperative vs. postoperative ISI was 0.88±0.23 vs. 1.06±0.45 (p=0.03). PPB was observed preoperatively in 23 (63%) patients vs. 24 (54%) postoperatively. Preoperative vs. postoperative CDI was 0.70±0.24 vs. 0.95±0.43 (p=0.002). Preoperative flexion was 91°±30° vs. 85°±24° postoperatively (p>0.05). CONCLUSION: Both PB and PPB are frequently observed after M-TKA. A reduction in PB and PPB alone does not improve postoperative range of motion.

Intraoperative computer-assisted prediction of intraarticular contact pressures in the knee during high tibial osteotomy.

OBJECTIVES: To develop an accurate intraoperative method to estimate changes in intraarticular contact pressures during high tibial osteotomy (HTO). METHODS: Changes in knee alignment and pressure were monitored in real time in seven cadaver specimens that received HTO. Intraarticular contact pressure (N/mm2 ) in each knee compartment was estimated based on extraarticularly acquired data (leg alignment, correction, and ankle tilt) and based on the application of an axial force of half bodyweight (400-450 N). RESULTS: Contact pressure estimation was more accurate in the lateral compartment (R2  = 0.940) than in the medial compartment of the knee (R2  = 0.835). The optimism-corrected R2 was 0.936 for the lateral compartment and 0.821 for the medial compartment. CONCLUSIONS: We have established a framework for estimating the change in intraarticular contact pressures based on extraarticular data. This research could be helpful in generating appropriate algorithms to estimate joint alignment changes based on applied loads.

An interdisciplinary consensus on the management of bone metastases from renal cell carcinoma.

Bone is a major site of haematogenous tumour cell spread in renal cell carcinoma (RCC), and most patients with RCC will develop painful and functionally disabling bone metastases at advanced disease stages. The prognosis of these patients is generally poor and the treatment is, therefore, aimed at palliation. However, RCC-associated bone metastases can be curable in select patients. Current data support a multimodal management strategy that includes wide resection of lesions, radiotherapy, systemic therapy, and other local treatment options, which can improve quality of life and survival. Nevertheless, the optimal approach for metastatic bone disease in RCC has not yet been defined and practical recommendations are rare. To improve the management and outcomes of patients with RCC and bone metastases, the International Kidney Cancer Coalition and the interdisciplinary working group on renal tumours of the German Cancer Society convened a meeting of experts with a global perspective to perform an unstructured review and elaborate on current treatment strategies on the basis of published data and expertise. The panel formulated recommendations for the diagnosis and treatment of patients with RCC and metastasis to the bone. Furthermore, the experts summarized current challenges and unmet patient needs that should be addressed in the future.

Long-term outcome in 324 polytrauma patients: what factors are associated with posttraumatic stress disorder and depressive disorder symptoms?

BACKGROUND: Physical impairment is well-known to last for many years after a severe injury, and there is a high impact on the quality of the survivor's life. The purpose of this study was to examine if this is also true for psychological impairment with symptoms of posttraumatic stress disorder or depression after polytrauma. DESIGN: Retrospective cohort outcome study. SETTING: Level I trauma centre. POPULATION: 637 polytrauma trauma patients who were treated at our Level I trauma centre between 1973 and 1990. Minimum follow-up was 10 years after the injury. METHODS: Patients were asked to fill in a questionnaire, including parts of the Posttraumatic Stress Diagnostic Scale, the Impact of Event Scale-Revised and the German Hospital Anxiety and Depression Scale, to evaluate mental health. Clinical outcome was assessed before by standardised scores. RESULTS: Three hundred and twenty-four questionnaires were evaluated. One hundred and forty-nine (45.9%) patients presented with symptoms of mental impairment. Quality of life was significantly higher in the mentally healthy group, while the impaired group achieved a lower rehabilitation status. CONCLUSIONS: Mental impairment can be found in multiple trauma victims, even after 10 years or more. Treating physicians should not only focus on early physical rehabilitation but also focus on early mental rehabilitation to prevent long-term problems in both physical and mental disability.

Robotic distal locking of intramedullary nailing: Technical description and cadaveric testing.

Interlocked intramedullary nailing is the treatment of choice for femoral shaft fractures. However, distal locking is a technically challenging part of the procedure that can result in distal femoral malrotation and high radiation exposure. We have tested a robotic procedure for robotic distal locking based on the computation of a drilling trajectory on two calibrated fluoroscopic images. Twenty distal holes were attempted in ten cadaveric femur specimens. Successful screw hole drilling was achieved at the first attempt in each of the ten specimens (20 drill holes in total). No failures were recorded. The average total number of images needed was 6.5 +/- 3.6. The average computation time was 16.5+/- 16.0 seconds. Robotic distal locking was feasible in this test and can be integrated into a fully robotic intramedullary nailing procedure.

[First results with a resorbable MgYREZr compression screw in unstable scaphoid fractures show extensive bone cysts]. / Erste Ergebnisse mit einer resorbierbaren MgYREZr-Kompressionsschraube bei der instabilen Kahnbeinfraktur zeigen eine massive Zystenbildung.

Osteosynthesis with headless compression screws is an established treatment option for unstable scaphoid fractures. Common implants are made of titanium alloy or steel and usually remain in place. Due to implant density and ferromagnetic properties, artefacts are common in postoperative imaging procedures, e.g. MRI. Now resorbable implants made of magnesium alloy (MgYREZr) have become available. They have biomechanical properties equivalent to human bone and may be used as an alternative to the nonresorbable screw systems.5 patients with acute scaphoid fractures were treated with a double-threaded screw made of MgYREZr. The fractures included three type A2 fractures, one type B2 fracture, and one type B3 fracture. All patients underwent clinical and radiological follow-up postoperatively, 6 weeks, 3 and 6 months and 1 year after surgery. ROM, gross grip strength and pain (VAS) were documented. The Modified Mayo Wrist Score was used. Standard X-rays of the wrist were taken preoperatively and at all follow-up visits. A CT scan was performed at least before and three months after surgery. In all X-rays malunion, resorption of the implant, implant loosening, cysts and bone healing (bridging trabecular structures) were described.All patients had a very good wrist score (95-100 points) after one year. There were no clinical complications. However, the X-rays revealed extensive resorption cysts in 3 out of the 5 patients. It was only after 6 months that the fractures were consolidated enough to allow physical work. Due to this considerable osteolysis, we did not include any further patients. Due to the observed extensive bone cysts and the long time period for bone healing, MgYREZr compression screws are currently not recommended for clinical use in scaphoid fractures. Further fundamental research is necessary.

Biomechanical comparison of two surgical techniques for press-fit reconstruction of the posterolateral complex of the knee.

BACKGROUND: To date, various surgical techniques to treat posterolateral knee instability have been described. Recent studies recommended an anatomical and isometric reconstruction of the posterolateral corner addressing the key structures, such as lateral collateral ligament (LCL), popliteus tendon (POP) and popliteofibular ligament (PFL). Two clinical established autologous respective local reconstruction methods of the posterolateral complex were tested for knot-bone cylinder press-fit fixation to assess efficacy of each reconstruction technique in comparison to the intact knee. NULL HYPOTHESIS: The knot-bone cylinder press-fit fixation for both anatomic and isometric reconstruction techniques of the posterolateral complex shows equal biomechanical stability as the intact posterolateral knee structures. STUDY DESIGN: This was a controlled laboratory study. METHODS: Two surgical techniques (Larson: fibula-based semitendinosus autograft for LCL and PFL reconstruction/Kawano: biceps femoris and iliotibial tract autograft for LCL, PFL and POP reconstruction) with press-fit fixation were used for restoration of posterolateral knee stability. Seven cadaveric knees (66 ± 3.4 years) were tested under three conditions: intact knee, sectioned state and reconstructed knee for each surgical technique. Biomechanical stress tests were performed for every state at 30° and 90° knee flexion for anterior-posterior translation (60 N), internal-external and varus-valgus rotation (5 Nm) at 0°, 30° and 90° using a kinemator (Kuka robot). RESULTS: At 30° and 90° knee flexion, no significant differences between the four knee states were registered for anterior-posterior translation loading. Internal-external and varus-valgus rotational loading showed significantly higher instability for the sectioned state than for the intact or reconstructed posterolateral structures (p < 0.05). There were no significant differences between the intact and reconstructed knee states for internal-external rotation, varus-valgus rotation and anterior-posterior translation at any flexion angles (p > 0.05). Comparing both reconstruction techniques, significant higher varus-/valgus stability was registered for the fibula-based Larson technique at 90° knee flexion (p < 0.05). CONCLUSIONS: Both PLC reconstructions showed equal biomechanical stability as the intact posterolateral knee structures when using knot-bone cylinder press-fit fixation. We registered restoration of the rotational and varus-valgus stability with both surgical techniques. The anterior-posterior translational stability was not influenced significantly. The Larson technique showed significant higher varus/valgus stability in 90° flexion. The latter is easier to perform and takes half the preparation time, but needs grafting of the semitendinosus tendon. The Kawano reconstruction technique is an interesting alternative in cases of missing autografts.

Nail-medullary canal ratio affects mechanical axis deviation during femoral lengthening with an intramedullary distractor.

INTRODUCTION: Callus distraction of the femur using an intramedullary distractor has several advantages over the use of external fixators. However, difficulty in controlling the mechanical axis during lengthening may cause deformities and knee osteoarthritis. Purpose of the study is to answer the following questions: (1) is lengthening with an intramedullary device associated with a medial or lateral shift of the mechanical axis? (2) Which factors are associated with varisation/valgisation of the mechanical axis during lengthening? MATERIALS AND METHODS: We analysed pre-treatment and post-treatment radiographs from 20 patients who underwent unilateral femoral-lengthening procedures using intramedullary distractors. Patients with acute correction of pre-existing deformities or combined ipsilateral femoral and tibial lengthening were excluded. Mechanical axis deviations, osteotomy level, and nail-medullary canal ratio were recorded. RESULTS: Compared to the preoperative axis, the mechanical axis shifted medially in 7 patients (varisation group) and laterally in 13 patients (valgisation group). The groups did not significantly differ regarding preoperative leg length discrepancy (LLD), mechanical axis alignment, LLD-cause and implants used. The nail-medullary canal ratio significantly differed between groups (p<0.001), being <85% in the varisation group and >85% in the valgisation group. The distance between the lesser trochanter and the osteotomy site was significantly longer in the valgisation group (58.9±16.3mm, middle third of the femur) compared to the varisation group (40.6±11.4mm, proximal third of the femur; p=0.02). CONCLUSION: The nail-medullary canal ratio should be considered during preoperative planning. To avoid a varisation effect-for example, in cases with pre-existing varus alignment-it would be advisable to perform an osteotomy at the middle third of the femur with implantation of a nail that fully covers the medullary canal at the osteotomy site. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Soft Tissue Coverage of the Lower Limb following Oncological Surgery.

The treatment of lower limb tumors has been shifted by advancements in adjuvant treatment protocols and microsurgical reconstruction from limb amputation to limb salvage. Standard approaches include oncological surgery by a multidisciplinary team in terms of limb sparing followed by soft tissue reconstruction and adjuvant therapy when indicated. For the development of a comprehensive surgical plan, the identity of the tumor should first be determined by histology after biopsy. Then the surgical goal and comprehensive treatment concept should be developed by a multidisciplinary tumor board and combined with soft tissue reconstruction. In this article, plastic surgical reconstruction options for soft coverage of the lower extremity following oncological surgery will be described along with the five clinical cases.

Vertebral fractures in motor vehicle accidents - a medical and technical analysis of 33,015 injured front-seat occupants.

Spinal injuries pose a considerable risk to life and quality of life. In spite of improvements in active and passive safety of motor vehicles, car accidents are regarded as a major cause for vertebral fractures. The purpose of this study was to evaluate the current incidence of vertebral fractures among front-seat occupants in motor vehicle accidents, and to identify specific risk factors for sustaining vertebral fractures in motor vehicle accidents. Data from an accident research unit were accessed to collect collision details, preclinical data, and clinical data. We included all data on front-seat occupants. Hospital records were retrieved, and radiological images were evaluated. We analysed 33,015 front-seat occupants involved in motor vehicle accidents over a 24-year period. We identified 126 subjects (0.38%) with cervical spine fractures, 78 (0.24%) with thoracic fractures, and 99 (0.30%) with lumbar fractures. The mean relative collision speeds were 48, 39, and 40 kph in subjects with cervical, thoracic, and lumbar spine fractures, respectively, while it was 17.3 kph in the whole cohort. Contrary to the overall cohort, these patients typically sustained multiple hits rather than simple front collisions. Occupants with vertebral fractures frequently showed numerous concomitant injuries; for example, additional vertebral fractures. The incidence of vertebral fractures corresponded with collision speed. Safety belts were highly effective in the prevention of vertebral fractures. Apart from high speed, complex injury mechanisms as multiple collisions or rollovers were associated with vertebral fractures. Additional preventive measures should focus on these collision mechanisms.

Navigated reconstruction of tibial head depression fractures by inflation osteoplasty.

BACKGROUND: Articular fracture reduction control remains a challenge even with the development of computer-assisted surgery. The Kyphoplasty procedure has shown advantages in treating vertebral fractures. One case report showed successful reduction of acetabular fractures using Kyphoplasty. OBJECTIVE: This study examines the efficacy of this method in reducing depressed tibial plateau fractures. METHODS: An insertion sleeve for the Kyphon balloon that could be calibrated by the navigation system was designed. A total of 30 test series in synthetic bone cubes were performed using fracture instruments of 2.5 mm, 5 mm and 15 mm diameter, respectively, creating three different depression fracture depths (mean 1.87 mm, 4.2 mm and 1.72 mm, respectively). The Kyphon balloon was used to attempt reduction of each fracture. The same setup was used for testing in five cadaveric tibia specimens. RESULTS: After reduction, there was a remaining depression depth mean in the synthetic bone of 0.27 mm for the 2.5 mm instrument; 2.1 mm for the 5 mm instrument; and 1.72 mm for the 15 mm instrument. We could not adequately reduce depression fractures in cadaveric testing. CONCLUSIONS: The Kyphon balloon was accurately placed with the aid of navigation. The depth was the decisive factor in the reduction of the fracture and not the diameter. In cadavers, depression fractures greater than 5~mm depth could not be reduced with our setup.

Rotational alignment in total knee arthroplasty: intraoperative inter- and intraobserver reliability of Whiteside's line.

INTRODUCTION: Proper rotational alignment is a critical step of total knee arthroplasty. For intraoperative determination of femoral rotation, Whiteside suggests a perpendicular line to the axis of the center of the trochlea and the intercondylar notch (Whiteside's line). METHOD: In a prospective clinical study, the intraoperative position of Whiteside's line was measured in 30 patients with the help of a navigation system. RESULTS: Whiteside's line was 2.1° ± 1.5° externally rotated compared to a navigation based computer calculated preliminary AP axis of the femur. The intraobserver-reliability after 3 repeated measurements each was 1.6° for the senior surgeon and 1.4° for the junior surgeon (p = 0.598, p = 0.968). The interobserver reliability between the measurements by the senior and junior surgeon was 1.4° (p = 0.547). CONCLUSION: Navigated intraoperative measurements of Whiteside's line showed a high inter- and intraobserver reliability. Considering the variability between Whiteside's line and the transepicondylar axis, intraoperative assessment of both the methods is recommended.

Head injury in polytrauma-Is there an effect on outcome more than 10 years after the injury?

INTRODUCTION: Head injuries are of great relevance for the prognosis of polytrauma patients during acute care. However, knowledge about the impact on the long-term outcome is sparse. Therefore, this study analysed the role of head injuries on the outcome of polytrauma patients more than 10 years after injury in a matched-pair analysis. PATIENTS AND METHODS: Out of 620 polytrauma patients with and without head injury, a matched-pair analysis with comparable age, injury severity and gender distribution and a minimum of 10 years follow-up was performed. The outcome and quality-of-life were measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form 12 (SF-12), Glasgow Outcome Scale (GOS) and other parameters. RESULTS: The matched-pair analysis consisted of 125 pairs (age 27.9 ± 1.2 years, ISS 20.0 ± 0.8 [head injury] vs ISS 19.8 ± 0.8 [no head injury]). A significant difference was shown for the GOS Score only (GOS head injury 4.3 ± 0.3 vs no head injury 4.9 ± 0.2, p = 0.01). The psychological outcome was similar in both groups. Both groups reported comparable subjective rehabilitation satisfaction. CONCLUSIONS: Matching pairs of equally injured polytrauma patients of same gender with and without head injury 10 years following trauma indicated significantly worse results in the GOS due to head injury.

Predictors of late clinical outcome following orthopedic injuries after multiple trauma.

BACKGROUND: The long-term clinical status of surviving patients with multiple injuries has not been well described. The aim of this study was to evaluate whether certain injury patterns predispose a patient to a poor clinical outcome 10 or more years after multiple injuries. METHODS: Patients who were treated at a level I trauma center at least 10 years before participation in this study were reinvited for a follow-up physical examination. Clinical outcome included the assessment of pain, gait, and various outcome scores (Short-Form [SF]-12, Lysholm, Merle D'Aubigne) were also used to measure outcome. STATISTICS: Binary logistic regression was used to test predictors of physical and psychosocial outcomes 10 years or longer after trauma. Differences between the types of injury and outcomes were assessed using Mann-Whitney and Kruskal Wallis tests. RESULTS: Of 1,034, 637 patients (62%) participated in this study. Predictors of poor physical and psychosocial functioning using a clinical outcome score at 10 or more years follow-up included lower extremity amputation (odds ratio = 15.08; 95% confidence interval = 1.87-121.61) and a higher Abbreviated Injury Scale (AIS) spine score (SF-12 Mental subscale [odds ratio = 0.78; 95% confidence interval = 0.64-0.96]). Other factors associated with worse outcome scores were presence of two or more articular injuries, lower extremity injuries, and a combination of shaft and articular injuries. CONCLUSION: If patients survived, traumatic lower extremity amputation and a high initial maximum AIS (MAIS) spine score was the only predictive parameter for an increased odds of adverse clinical outcomes late after trauma. Injuries associated with these outcomes should be the focus of attention regarding injury prevention and priority in care.

Clinical re-examination 10 or more years after polytrauma: is there a gender related difference?

BACKGROUND: : Previous studies documented that premenopausal women better tolerate severe injuries than men in regards to mortality and intensive care complications. We test the hypothesis whether surviving women have a better long-term outcome than surviving men. METHODS: : We reassessed 637 polytrauma patients 10 or more years (mean 17 +/- 5 years) after trauma. Mental health was assessed by the posttraumatic stress diagnostic scale and the Hospital Anxiety and Depression Scale. The clinical outcome was assessed by standardized scores (Hannover Score for Polytrauma Outcome and short form-12). A physical examination was performed by an orthopedic surgeon. RESULTS: : We studied 479 men (M; 75.4%) and 158 women (F; 24.6%) aged M = 26.7 +/- 12.2 versus F = 25.9 +/- 13.0 years (p = 0.47). Injury Severity Score showed M = 20.4 +/- 9.9 versus F = 21.7 +/- 9.7 (p = 0.13). Women showed a higher rate of posttraumatic stress disorder (F = 14.5% vs. M = 6.2%; p = 0.035) and psychologic support (F = 28.0% vs. M = 15.0%; p < 0.001), longer duration of rehabilitation, and longer sick leave time. Quality-of-life was significantly lower in women (Short form-12 psychologic F = 48.6 +/- 10.8 vs. M = 50.8 +/- 9.4; p = 0.02), but the same rate of women (75.3%) and men (75.4%; p = 0.995) felt well rehabilitated. CONCLUSION: : Late after polytrauma, women suffer more severe psychologic impairment than men who had similar injuries. This finding is independent of physical impairment and the subjective feeling of a good rehabilitation outcome. Clinically, women require special support even years after injury to improve their psychologic status. In the future, they might benefit from early concomitant psychologic treatment if mental problems are suspected.

Long-term outcome after joint reconstruction or medial resection arthroplasty for anterior SCJ instability.

INTRODUCTION: In the present study, the long-term results of 11 patients with anterior sternoclavicular joint (SCJ) instability are reported. All included patients had an anterior SCJ instability and due to delayed diagnosis, operative treatment was not done immediately. METHOD: The patients had a mean age of 29.2 years (range 16-63 years). One patient sustained concomitant injuries. Six patients had resection arthroplasty. Five patients had reconstruction of the SCJ with transosseous tension band PDS fixation or ligament reconstruction with additional wire cerclage. The results of treatment were evaluated after a mean follow-up period of 9.9 years (range 1-27 years) using the ASES, DASH and power-, age and gender adjusted Constant-Murley Score. RESULTS: In general, the mean values of the different scores (ASES 79.8; DASH 11.8; Constant-Murley 81%) demonstrated good outcome. The outcome evaluation of the patients who had SCJ reconstruction did not differ significantly from the patients who had medial resection arthroplasty. The rate of postoperative pain or instability was low using visual analog scale and did not differ significantly between the groups. The outcome results of the reconstruction group were equal to the results of the resection group when SCJ-reconstruction was performed soon after SCJ injury. One patient in the resection group (6 patients) demonstrated poor results due to continued instability of the remaining clavicle. CONCLUSION: We concluded that patient selection and a specific clinical indication for operative treatment are crucial. Resection of the medial clavicle results in good functional outcome when the costoclavicular ligament is preserved or reconstructed.

Influence of workers' compensation eligibility upon functional recovery 10 to 28 years after polytrauma.

BACKGROUND: Previous studies have shown that work-related injuries are often associated with inferior outcomes. The aim of the current study was to compare the long-term functional outcome after polytrauma between work-related and non-work-related injuries at a minimum follow-up of 10 years. METHODS: Six hundred thirty-seven polytrauma patients were evaluated using a patient questionnaire and a physical examination. The average follow-up was 17.5 years (range 10-28 years); the average Injury Severity Score (ISS) was 20.7 (range 4 to 54). RESULTS: A multivariate analysis, with adjustments for age, sex, injury severity, and injury pattern, demonstrated that work-related injuries resulted in significantly inferior outcomes measured by the Hannove Score for Polytrauma Outcome (HASPOC), 12-Item Short-Form Health Survey (SF-12), requirement for medical aids and devices, length of rehabilitation, and retirement status (P < .05). CONCLUSIONS: Polytrauma patients receiving workers' compensation achieve significantly inferior long-term outcomes than other patients. The obtained results demonstrate that psychosocial variables such as insurance status have a significant impact on the functional recovery following polytrauma.

Combination of femoral fracture treatment and corrective osteotomy in a child with osteogenesis imperfecta.

The main feature of osteogenesis imperfecta is an excessive fragility and deformability of the bones owing to reduced mass and bone quality. This leads to angular deformity and frequent fractures. These fractures usually heal rapidly, and conservative treatment is the norm. In displaced and unstable fractures, elastic intramedullary nailing is a treatment option. We report a case of a 3-year-old child with osteogenesis imperfecta type I who suffered an undisplaced femoral shaft fracture in the presence of a preexisting 32 degrees femoral antecurvation. This deformity greatly increases the risk of a refracture due to the pathological induction of stress risers. Therefore, fracture treatment by unreamed elastic intramedullary nailing was combined with simultaneous correction osteotomy, resulting in anatomic alignment and uncomplicated fracture healing. The single-stage surgical stabilization performed allowed rapid mobilization along with a decreased likelihood of refracture.