Numerical evaluation of internal femur osteosynthesis based on a biomechanical model of the loading in the proximal equine hindlimb.

Femoral fractures are often considered lethal for adult horses because femur osteosynthesis is still a surgical challenge. For equine femur osteosynthesis, primary stability is essential, but the detailed physiological forces occurring in the hindlimb are largely unknown. The objective of this study was to create a numerical testing environment to evaluate equine femur osteosynthesis based on physiological conditions. The study was designed as a finite element analysis (FEA) of the femur using a musculoskeletal model of the loading situation in stance. Relevant forces were determined in the musculoskeletal model via optimization. The treatment of four different fracture types with an intramedullary nail was investigated in FEA with loading conditions derived from the model. The analyzed diaphyseal fracture types were a transverse (TR) fracture, two oblique fractures in different orientations (OB-ML: medial-lateral and OB-AP: anterior-posterior) and a "gap" fracture (GAP) without contact between the fragments. For the native femur, the most relevant areas of increased stress were located distally to the femoral head and proximally to the caudal side of the condyles. For all fracture types, the highest stresses in the implant material were present in the fracture-adjacent screws. Maximum compressive (-348 MPa) and tensile stress (197 MPa) were found for the GAP fracture, but material strength was not exceeded. The mathematical model was able to predict a load distribution in the femur of the standing horse and was used to assess the performance of internal fixation devices via FEA. The analyzed intramedullary nail and screws showed sufficient stability for all fracture types.

Comparison between intramedullary nail and conventional plate for displaced intra-articular calcaneal fractures: A meta-analysis.

OBJECTIVES: This study aimed to compare the efficacy and safety of the intramedullary nail and conventional plate for the treatment of displaced intra-articular calcaneal fractures from clinical comparative trials. MATERIALS AND METHODS: A comprehensive search of English databases was carried out in the Springer, PubMed, ScienceDirect, Web of Science, and Cochrane Library databases until September 2023. Studies on calcaneal fractures treated by an intramedullary nail or a plate were considered for inclusion. Endpoints included duration of operation, length of hospital stay, the Visual Analog Scale (VAS) score, postoperative functional score, radiological parameters, and complications. The mean difference (MD) and risk difference (RD) as the combined variables, as well as the 95% confidence intervals, (CIs) were calculated. RESULTS: Five retrospective controlled studies covering 473 feet at the one-year follow-up met the inclusion criteria. The meta-analysis demonstrated that there were significant differences in the duration of operation (MD: -10.81; 95% CI: -16.32, -5.31; p=0.0001), length of hospital stay (MD: -3.65; 95% CI: -4.35, -2.95; p<0.00001). No significant differences were found regarding postoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (MD: 0.36; 95% CI: -3.89, 4.61; p=0.87), VAS (MD: 1.95; 95% CI: -0.30, 4.21; p=0.09), or postoperative Böhler angle (MD: 0.94; 95% CI: -0.04, 1.92; p=0.06) between the two groups. The incidence of total complications (RD: -0.31; 95% CI: -0.46, -0.17; p<0.0001) and wound-healing complications (RD: -0.16; 95% CI: -0.30, -0.03; p=0.02) were lower in the intramedullary nail group. There were no significant differences in the incidences of revision surgery, implant removal, superficial wound infection, deep infection, and nonunion. CONCLUSION: Compared to conventional plates, the intramedullary nail showed a shorter duration of operation, reduced length of hospital stay, and fewer postoperative total complications and wound-healing complications in treating displaced intra-articular calcaneal fractures.

Finite element analysis of the stability of retrograde intramedullary nail and plate-screw combinations for periprosthetic femoral fractures following total knee replacement.

OBJECTIVE: Periprosthetic fractures following total knee replacement are rare but challenging. The goal of the treatment is to achieve the most stable fixation that allows early mobilization. Therefore, the aim of this study was to evaluate the biomechanical results of the use of different fixation systems in the treatment of distal femur periprosthetic fractures with finite element analysis. MATERIALS AND METHODS: A total knee prosthesis was implanted in Sawbone femur models. A transverse fracture line was created in the supracondylar region and was fixed in four different groups. In group 1, fracture line fixation was fixed using retrograde intramedullary nailing. In group 2, fixation was applied using a lateral anatomic distal femoral. In group 3, in addition to the fixation made in group 1, a lateral anatomic distal femoral plate was used. In group 4, in addition to the fixation made in group 2, a 3.5 mm Limited Contact Dynamic Compression Plate (LC-DCP) was applied medially. Computed Tomography (CT) scans were taken of the created models and were converted to three-dimensional models. Axial and rotational loading forces were applied to all the created models. RESULTS: The least deformation with axial loading was observed in the double plate group. Group 3 was determined to be more advantageous against rotational forces. The greatest movement in the fracture line was found in group 2. The application of the medial plate was determined to reduce the tension on the lateral plate and increase stability in the fracture line. CONCLUSIONS: Combining a lateral anatomic plate with intramedullary nailing or a medial plate was seen to be biomechanically more advantageous than using a lateral plate or intramedullary nailing alone in the treatment of distal femoral periprosthetic fractures.

[Treatment of irreducible intertrochanteric femoral fracture in elderly by folding top technique combined with right-angle pliers prying and pulling under G-arm X-ray fluoroscopy].

Objective: To explore the effectiveness of irreducible intertrochanteric femoral fracture in the elderly by treating with folding top technique and right-angle pliers prying and pulling under G-arm X-ray fluoroscopy. Methods: The clinical data of 74 elderly patients with irreducible intertrochanteric femoral fracture admitted between February 2016 and December 2022 and met the selection criteria were retrospectively analyzed. Among them, 38 cases were treated with folding top technique combined with right-angle pliers prying and pulling under G-arm X-ray fluoroscopy and intramedullary nailing fixation (study group), and 36 cases were treated with limited open reduction combined with other reduction methods and intramedullary nailing fixation (control group). There was no significant difference in baseline data between the two groups, such as age, gender, cause of injury, affected side and classification of fractures, complicated medical diseases, and time from injury to operation ( P>0.05). The operation time, intraoperative blood loss, hospital stay, fracture reduction time, fracture healing time, and complications of the two groups were recorded and compared. The quality of fracture reduction was evaluated by Baumgaertner et al. and Chang et al. fracture reduction standards. Results: Patients in both groups were followed up 10-14 months, with an average of 12 months. The operation time and intraoperative blood loss in the study group were significantly less than those in the control group ( P<0.05), there was no significant difference in hospital stay between the two groups ( P>0.05). At 2 days after operation, according to the fracture reduction standards of Baumgaertner et al. and CHANG Shimin et al., the quality of fracture reduction in the study group was better than that in the control group, and the fracture reduction time in the study group was shorter than that in the control group, with significant differences ( P<0.05). After operation, the fractures of the two groups all healed, and there was no significant difference in healing time between the two groups ( P>0.05). During the follow-up, there was no complication such as incision infection, internal fixation failure, deep venous thrombosis of lower limbs, intramedullary nail breakage, spiral blade cutting, or hip varus in the two groups, except for 2 cases of coxa vara in the control group. Conclusion: For the irreducible intertrochanteric femoral fracture, using folding top technique combined with right-angle pliers prying and pulling under G-arm X-ray fluoroscopy can obviously shorten the operation time, reduce the intraoperative blood loss, and improve the quality of fracture reduction.

Interlocking intramedullary nail for forearm diaphyseal fractures in adults-A systematic review and meta-analysis of outcomes and complications.

PURPOSE: The purpose of this systematic review is to examine the outcomes, complications, and potential advantages of using anatomical interlocking intramedullary nails (IMN) in the treatment of radius and ulnar shaft diaphyseal fractures in adults. METHODS: Medline, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched between January 2000 and January 2023. Studies meeting criteria were observational or randomized controlled trials evaluating outcomes in IMN for adult diaphyseal forearm fractures. Standardized data extraction was performed and a quality assessment tool was used to evaluate individual study methodology. Descriptive statistics for interventions, functional outcomes, and complications were reported. Meta-analysis was performed for patient-reported outcome measures and operative time. RESULTS: A total of 29 studies involving 1268 patients were included with 764 (60%) undergoing IMN, 21% open reduction and internal fixation (ORIF), and 9% hybrid fixation. There was no significant difference between groups in DASH and Grace-Eversmann scores. Operative time was significantly shorter in IMN compared with ORIF. The DASH scores were: 13.1 ± 6.04 for IMN, 10.17 ± 3.98 for ORIF, and 15.5 ± 0.63 in hybrids. Mean operative time was 65.3 ± 28.7 in ORIF and 50.8 ± 17.7 in IMN. Complication rates were 16.7% in the IMN group, 14.9% in ORIF, and 6.3% in hybrid constructs. There were 11 cases of extensor pollicis rupture in the IMN group. Average IMN pronation and supination were 78.3° ± 7.9° and 73° ± 5.0°, respectively. Average ORIF pronation and supination was 82.15° ± 1.9° and 79.7° ± 4.5°, respectively. CONCLUSIONS: Similar functional outcomes and complication rates along with shorter operative times can be achieved with IMN compared with ORIF. The use of IMN is promising, however, higher quality evidence is required to assess appropriate indications, subtle differences in range of motion, implant-related complications, and cost-effectiveness. Trail Registration PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42022362353).

Bilateral intertrochanteric fractures in an elderly patient following high-energy trauma: a case report.

BACKGROUND: Cases of bilateral hip fractures are rare, and even more so are cases of bilateral intertrochanteric fractures. Common causes include trauma, internal diseases, and primary or secondary bone diseases. We report a case of bilateral intertrochanteric fractures in an elderly patient following a severe car accident, a scenario not extensively reported in existing literature. CASE PRESENTATION: We report on an 84-year-old male who suffered severe trauma from a car accident, resulting in multiple injuries and shock state, with pain and limited mobility in both hip joints. After examination and imaging studies, the patient was diagnosed with multiple injuries and bilateral intertrochanteric fractures. Following emergency resuscitation, he was admitted to the orthopedic ward. A pre-surgical multidisciplinary team (MDT) consultation was convened to optimize surgical conditions. The patient underwent successful one-stage bilateral intramedullary nailing. The patient was assisted to stand with a walker on the third day after surgery. Six months post-surgery, the patient resumed outdoor activities. CONCLUSION: Managing bilateral intertrochanteric fractures, particularly in the elderly with severe trauma, is notably challenging due to their rarity. However, a coordinated multidisciplinary approach and one-stage bilateral internal fixation can lead to effective treatment outcomes and favorable prognoses.

Unravelling variations: an examination of entry point selection in proximal femoral cephalomedullary nailing.

BACKGROUND: The exact positioning of the cephalomedullary (CM) nail entry point for managing femoral fractures remains debatable, with significant implications for fracture reduction and postoperative complications. This study aimed to explore the variability in the selection of the entry point among trauma surgeons, hypothesizing potential differences and their association with surgeon experience. METHODS: In this prospective multicenter study, 16 participants, ranging from residents to senior specialists, partook in a simulation wherein they determined the optimal entry point for the implantation of a proximal femoral nail antirotation (PFN-A; DePuy Synthes) in various femora. The inter- and intra-observer variability was calculated, along with comprehensive descriptive statistical analysis, to assess the variability in entry point selection and the impact of surgeon experience. RESULTS: In this study, the mean distance from the selected entry points to the calculated mean entry point was 3.98 mm, with a smaller distance observed among surgeons with more than 500 implantations (ANOVA, p = 0.050). Intra-surgeon variability for identical femora averaged at 5.14 mm, showing no significant differences across various levels of surgical experience or training. Notably, 13.6% of selected entry points would not allow a proper intramedullary positioning of the implant, thereby rendering anatomical repositioning unfeasible. Among these impossible entry points, a significant skew towards anterior placement was observed (70.6% of the impossible entry points), with a smaller fraction being overly lateral (27.5%) or medial (13.7%). On a patient level, the impossibility rate varied widely from 0 to 35% among the different femora examined, with a significantly higher rate seen in younger patients (mean age 55.02 versus 60.32; t-test for independent samples, p = 0.04). CONCLUSIONS: Significant variations exist in surgeons' selection of entry points for proximal femoral nailing, underscoring the task's complexity. Experience does not prevent the choice of unfeasible entry points, emphasizing the inadequacy of a universal approach and pointing towards the necessity for a patient-specific strategy for improved outcomes. TRIAL REGISTRATION NUMBER: DRKS00032465.

Percutaneous intramedullary screw or rush pin fixation of unstable ankle fractures in patients with fragile soft tissue - retrospective study of 80 cases.

INTRODUCTION: The standard surgical procedure for unstable ankle fractures is fixation of the lateral malleolus with a plate and screws. This method has a high risk of complications, especially among patients with fragile skin conditions. The aim of this study was to estimate the re-operation rates and identify complications in patients with an unstable ankle fracture, surgically treated with an intramedullary screw or rush pin. MATERIALS AND METHODS: We identified all patients who were surgically treated with either a 3.5-mm screw or rush pin at Aarhus University Hospital, Denmark, from 2012 to 2018. Major complications were re-operations within three months. We included 80 patients, of which 55 (69%) were treated with a 3.5-mm intramedullary screw and 25 (31%) with a rush pin. The majority of the study population was female (59) and the mean age was 75 (range 24 to 100) years. Of the 80 patients included, 41 patients had more than 2 comorbidities. RESULTS: Three patients underwent re-operation within three months due to either fracture displacement or hardware cutout. Radiographs obtained after six weeks showed that nine patients had loss of reduction. Additionally, four patients had superficial wound infections and six patients had delayed wound healing. CONCLUSIONS: Intramedullary fixation of distal fibula fractures with either a screw or rush pin has low re-operation rates. However, the high proportion of patients with radiological loss of reduction is concerning.

A retrospective investigation on clinical and radiographic outcomes of distal tibial fractures after intramedullary nailing using the lateral parapatellar extra-articular approach.

INTRODUCTION: According to reports, the modified extra-articular parapatellar approach allows the performance of tibial nailing in the semi-extended position without the concern of joint violation. However, there remains no special study that has provided a detailed assessment of the benefits and risks of this approach for treating distal tibial fractures (DTFs). The aim of this retrospective study was to investigate the clinical and radiological outcomes of patients with DTFs after intramedullary nailing using a lateral parapatellar extra-articular (LPE) approach in comparison to using the suprapatellar (SP) and transpatellar (TP) approaches. METHODS: Data were collected from 99 patients with a minimum follow-up period of 12 months. Comparisons were conducted between the groups regarding the number of intraoperative fluoroscopies, complications, knee pain, knee range of motion (ROM), the Lysholm Knee Scale (LKS), the Olerud-Molander Ankle Score (OMAS) and radiological findings. RESULTS: The demographic characteristics were comparable between the groups. Fewer intraoperative fluoroscopies were performed in the LPE (27.47 ± 4.98) and SP (26.03 ± 5.12) groups than in the TP group (30.20 ± 7.42; P<0.001). When compared with the other two approaches, the LPE approach was associated with less knee pain (P<0.001) and better knee ROM (P<0.001) at one week postoperative. No significant intergroup differences were detected in the incidence of complications, LKS scores (P = 0.687) and OMAS (P = 0.926). Radiological findings demonstrated that postoperative tibial alignment (P = 0.853), the time of bony union and rate of non-union were similar between the groups. CONCLUSION: The LPE approach can serve as a safe and effective option for tibial nailing, as it offers favourable outcomes in knee pain relief and knee ROM in the early postoperative period and is equivalent to the other two approaches in terms of the incidence of complications, fracture healing, functional recovery and postoperative alignment for patients with DTFs.

[Comparative study of minimally invasive titanium elastic nail and steel plate on the treatment of fracture of tibiofibular fracture in adults].

OBJECTIVE: To compare the clinical outcomes of using elastic intramedullary nail and plate to fix fibular fracture. METHODS: The 60 patients with tibiofibular fractures admitted from January 2015 to December 2022 were divided into two groups:intramedullary nail group and plate group, 30 cases each, intramedullary nail group was treated with elastic intramedullary nail fixation group, plate group was treated with steel plate and screw fixation group. Intramedullary nail group, there were 18 males and 12 females, aged from 22 to 75 years old with an average of (39.4±9.8) years old, including 24 cases of traffic accidents injury, 6 cases of falling injury, 23 cases of closed fractures, 7 cases of open fractures. Steel plate group, there were 15 males and 15 females, aged from 24 to 78 years old with an average of (38.6±10.2) years old. The 22 cases were injured by traffic accident, 8 cases were injured by falling. The 24 cases were closed fractures and 6 cases were open fractures. The operation time, intraoperative bleeding, American Orthopedic Foot and Ankle Society (AOFAS) ankle and hind foot scores, clinical healing time of fibula and the incidence of wound complications were compared between the two groups. RESULTS: The patients in both groups were followed up for 6 to 21 months, with an average of (14.0±2.8) months. Compared with plate group, intramedullary nail group had shorter operative time, less bleeding, shorter clinical healing time of fibula, and lower infection rate of incision, and the difference was statistically significant (P<0.05). There were 2 cases of delayed healing in intramedullary nail group, 1 case of nonunion in plate group, and 2 cases of delayed healing in plate group, and there was no statistically significant difference between the two groups (P>0.05). In the last follow-up, according to the AOFAS scoring standard, the ankle function in intramedullary nail group was excellent in 17 cases, good in 12 cases, fair in 1 case, with an average of (88.33±4.57) points, while in plate group, excellent in 16 cases, good in 10 cases, fair in 4 cases, with an average of (87.00±4.14) points;There was no statistical difference between the two groups (P>0.05). CONCLUSION: Elastic intramedullary nail has the advantages of short operation time, less intraoperative bleeding, short fracture healing time and less incision complications in the treatment of fibular fracture, which is worthy of clinical application.

Posterior Cruciate Ligament Injury After Retrograde Nailing of Periprosthetic Distal Femur Fractures: A Report of 2 Cases.

CASE: A 51-year-old man and 64-year-old woman with bilateral cruciate-retaining total knee arthroplasties (CR-TKAs) who sustained unilateral periprosthetic distal femur fractures above their CR-TKA and experienced knee instability secondary to an iatrogenic posterior-cruciate-ligament (posterior cruciate ligament [PCL]) injury from retrograde intramedullary nailing. Both patients recovered knee stability after undergoing revision surgery. CONCLUSION: Many CR-TKA designs have sufficient medial-lateral intercondylar distance to place a retrograde nail, femoral components with a relatively posterior transition from the trochlear groove to the intercondylar box will necessitate a nail starting point closer to the PCL origin. This may contribute to iatrogenic postoperative knee instability for patients with CR-TKA designs.

Outcomes following surgical fixation of Gustilo-Anderson IIIb open tibial fractures.

There is no consensus as to the optimal skeletal fixation method for Gustilo-Anderson IIIb fractures. External fixation methods have previously shown higher rates of superficial infection, whilst internal fixation has shown higher risk of deep infection, but lower risk of other complications. This paper investigates outcomes in open tibial fractures based on fixation method. A retrospective review was performed for patients presenting to an ortho-plastic unit with GA IIIb tibial fractures between June 2013 and October 2021. 85 patients were identified. The most common implant was an intramedullary nail (IMN), used in 29 patients (34.1%); open reduction and internal fixation (ORIF) was performed in 16 patients (18.8%). 18 patients (21.2%) were definitively managed with a frame alone. Mean follow-up from was 18 months (2-77). Patients with ORIF needed a mean of 3.37 operations; it was 2.48 for IMN which was significantly different from frames at 5.00 (p=0.000). The mean time to bony union after definitive fixation was 11.4 months. This differed depending on the implant used for fixation, with ORIF at 7.1 months, 10.1 for IMN, and frames at 17.2 months; ORIF significantly differed from frames (p=0.009). Superficial infection was common, seen in 38.8% of patients, and only 3 patients (4%) developed deep infections involving metalwork, with no difference in rates of either based on fixation method This study supports that ORIF has faster healing times, with less time to union compared to frames. It also shows that no implant was superior to another in terms of outcomes.

Treatment of presumed aseptic non-union of the humeral shaft by osteosynthesis combining intramedullary nailing and screw plate.

In 2020, the most common treatment for presumed aseptic non-union of the humeral shaft seems to be decortication, often associated with bone autografting, and stabilized by a screw plate. We propose to evaluate an original technique of rigid osteosynthesis combining intramedullary nailing and screw plate. Between January 2004 and January 2020, 45 patients underwent treatment of presumed aseptic non-union of the humeral shaft by osteosynthesis combining intramedullary nailing and a screw plate. The minimum radio-clinical follow-up was one year postoperatively. The series included 19 men and 26 women with a mean age of 53 years (range 19-84 years). Bone consolidation was achieved in 43 patients, a rate of 95.5%. Comparing patients who achieved bone consolidation with the two failed consolidations did not reveal any statistically significant factor. Interobserver agreement was almost perfect (k=0.93) for the use of the RUST for humeral shaft fractures treated with intramedullary nailing and screw plate. In our study, the treatment of presumed aseptic non- union of the humeral shaft with an osteosynthesis combining intramedullary nailing and screw plate gives, with 95.5% of bone consolidation, results equal to or even superior to the different treatments currently described in the literature.

Suprapatellar tibial nailing: intraoperative arthroscopic evaluation and results at a minimum of 12 months follow-up.

To arthroscopically evaluate the intra-articular structures before and after placement of an intramedullary tibial nail using the suprapatellar approach and to assess the 1-year results. All patients with a tibial fracture that underwent intramedullary tibial nailing using the suprapatellar approach with a minimal follow-up of 12 months were included. Diagnostic intraoperative knee arthroscopy was performed before and immediately after insertion of the IMN. A radiological and clinical evaluation and VAS score of the patients was collected postoperatively. In total, 36 patients were included. The mean follow-up period was 14.9 ± 4.9 months. The mean age of the patients was 45.5 ± 18.8 years. The mean visual analog scale (VAS) score at 12 months was 1.0 ± 1.5. The complication rate was 19.4% and the reoperation rate was 16.7%. Union of the fractures was achieved in 33 patients (91.6%) after primary surgery after a mean of 6.1 ± 1.8 months. A change in the patellofemoral cartilage after insertion of the nail was seen in 1 patient. The suprapatellar procedure for tibia fractures resulted in excellent VAS scores and union rates at 1-year follow up, with a complication of articular damage to the PF joint in 2.8%.

Evaluation of the mechanical behaviour of the expandable wedge locked nail fixation in retrograde use: A finite element study.

INTRODUCTION: In literature, there have been many studies conducted to research the alternatives of standard interlocking intramedullary nailing. The expandable wedge locked nail fixation, which is thought as a new alternative to the standard interlocking nailing, has been presented in previous numerical studies. The antegrade usage of the wedge locked nail fixation has provided promising results. From this point, the aim of the study is to evaluate mechanical behavior of its retrograde usage on femur models. Additionally, another aim of the study is to investigate the effect of fracture level on mechanical properties of the fixation. MATERIALS AND METHODS: The mechanical behaviors of the wedge locked nail and standard interlocking nail fixations were compared by finite element methods. Sawbones femurs having osteotomies at five different levels to simulate different fractures were fixed with wedge locked nail or interlocking nail by using retrograde approach. With respect to the fracture level, two different nail lengths were used. Axial compression load was applied to fixations. The mechanical behaviors of the fixations were evaluated with respect to stiffness of the fixations and stresses occurred on both implants and bones. RESULTS: Any of the wedge locked nail fixation did not slip at canal. The stress and stiffness results were mostly close with each other for both nail types. The maximum stresses at locking elements or bones contacting these elements increased with decreased distance between the fracture and relevant locking elements. DISCUSSION: The wedge locked nail fixation showed comparable results to the standard interlocking nail fixation with respect to the stiffness and stress. Under axial loading, wedge locked nail provided a secured fixation without any slippage and preserved its position inside the medullary canal. It may be thought as a safe alternative to the standard interlocking nail fixation for retrograde usage. Additionally, according to stress results, it is advised to the surgeons to avoid a close locking to the fracture line.

Comparison of the clinical outcomes between proximal femoral nail anti-rotation with cement enhancement and hemiarthroplasty among elderly osteoporotic patients with intertrochanteric fracture.

BACKGROUND: The proximal femoral nail anti-rotation (PFNA) with cement enhancement enhances the anchorage ability of internal fixation in elderly with osteoporotic intertrochanteric fracture. However, whether it is superior to hemiarthroplasty is still controversial. The present study aimed to determine which treatment has better clinical outcomes among older patients. METHODS: We retrospectively analyzed 102 elderly patients with osteoporosis who developed intertrochanteric fractures and underwent PFNA combined with cement-enhanced internal fixation (n = 52, CE group), and hemiarthroplasty (n = 50, HA group) from September 2012 to October 2018. All the intertrochanteric fractures were classified according to the AO/OTA classification. Additionally, the operative time, intraoperative blood loss, intraoperative and postoperative blood transfusion rates, postoperative weight-bearing time, hospitalization time, Barthel Index of Activities Daily Living, Harris score of hip function, visual analog (VAS) pain score, and postoperative complications were compared between the two groups. RESULTS: The CE group had significantly shorter operative time, lesser intraoperative blood loss, lower blood transfusion rate, and longer postoperative weight-bearing time than the HA group. The CE group had lower Barthel's Index of Activities of Daily Living, lower Harris' score, and higher VAS scores in the first and third months after surgery than the HA group, but no difference was observed between the two groups from 6 months to 12 months. There was no significant difference in the total post-operative complications between the two groups. CONCLUSION: The use of PFNA combined with a cement-enhanced internal fixation technique led to shorter operative time and lesser intraoperative blood loss and trauma in elderly patients as compared to HA.

Comparative Outcomes of Elastic Stable Intramedullary Nailing vs. Plate Fixation in Pediatric Femoral Shaft Fractures. A Prospective Study.

BACKGROUND: Pediatric femoral fractures are common in emergency rooms, with treatment options varying by age. This study compares elastic stable intramedullary nailing (ESIN) and plate fixation for diaphyseal femoral fractures in children aged 5-10. MATERIAL AND METHODS: Conducted at Al-Kindi Teaching Hospital, Baghdad, from December 2017 to December 2019, this prospective study included 32 children with closed transverse diaphyseal femoral fractures. Patients were divided into two groups: 16 treated with ESIN (Group 1) and 16 with plate fixation (Group 2). Criteria excluded comminuted, open, or pathological fractures. RESULTS: Group 1 had a mean age of 7.1 years and weight of 23.7 kg; Group 2 had a mean age of 7.8 years and weight of 30.9 kg. ESIN resulted in shorter operative times (58.4 minutes), earlier weight-bearing, and quicker fracture union (8.8 weeks) compared to plate fixation (76.3 minutes, 11.9 weeks). Blood loss was significantly less in Group 1 (32.8 ml) versus Group 2 (205.0 ml). No significant differences in wound healing or leg length discrepancies were observed. CONCLUSIONS: 1. Our study indicates a preference for Elastic Stable Intramedullary Nailing (ESIN) over plate fixation for pediatric femoral shaft fractures in children aged 5-10 years. 2. ESIN is associated with shorter operative times and faster commencement of weight-bearing, critical in pediatric recovery. 3. While ESIN is generally preferable, plate fixation may be better suited in certain clinical scenarios, emphasizing the importance of personalized treatment. 4. Based on our findings, ESIN is recommended for treating transverse diaphyseal femur fractures in the specified pediatric age group. 5. Recommends further studies, including randomized controlled trials, for a more comprehensive understanding of these treatments' long-term outcomes.

Is Elastic Stable Intramedullary Nailing a Viable Treatment Option for Diaphyseal Fractures of the Humerus in Adults? A 29-case Series Prospective Study.

BACKGROUND: Humerus shaft fractures are common in orthopaedic practice. The emphasis in treatment has shifted from prolonged immobilisation to early mobilisation and internal fixation when needed for a quicker return to normal function. Internal fixation methods include plate osteosynthesis and intramedullary nailing. This study specifically evaluated the effectiveness of flexible intramedullary nails in treating diaphyseal humeral fractures. MATERIAL AND METHODS: Between April 2007 and January 2010, Alexandria University Hospital treated 29 patients (21 males, 8 females) with diaphyseal humeral fractures. Treatment involved closed reduction and percutaneous fixation using two flexible nails. Patients, aged 17 to 65 with a mean age of 32, were included if they did not have pathological fractures, were above 16 years old, and were medically suitable. Causes included pedestrian vehicle accidents (17 cases) and falls or sports-related activities (12 cases). Surgical intervention occurred 1 to 8 days after the injury. RESULTS: Between April 2007 and January 2010, Alexandria University Hospital treated 29 patients (21 males, 8 females) for diaphyseal humeral fractures using closed reduction and percutaneous fixation with two flexible nails. Patients, aged 17 to 65, were monitored for an average of 18 months. Radiographic assessments showed complete union in nineteen fractures within 13 to 21 weeks. One patient experienced non-union but was successfully treated with bone grafting and plating. There were no significant intraoperative complications. Notably, four patients with preoperative radial nerve injuries recovered within 6 to 8 weeks. Evaluation using the Stewart and Hundley Scoring technique showed excellent outcomes for 60% of patients, good outcomes for 30%, fair outcomes for 5%, and poor outcomes for 5%. CONCLUSIONS: 1.The Elastic Stable Intramedullary Nailing (ESIN) technique shows promise in the treatment of humeral shaft fractures. 2. However, the success of treatment may depend on various factors, including patient age, fracture characteristics, and the presence of complications such as open fractures and radial nerve palsy. 3. Careful consideration of these factors is necessary when selecting a treatment approach for humeral shaft fractures.

Radiographic outcomes and non-union factor analysis in fragmentary segmental femoral shaft fractures (AO/OTA 32C3) treated with reamed antegrade nailing.

This study retrospectively assessed radiographic outcomes and risk factors associated with non-union in femoral shaft fragmentary segmental fractures (AO/OTA 32C3) treated with reamed antegrade intra-medullary nailing. Radiological outcomes, including union and alignment, were evaluated. The risk factors for non-union were investigated, including demographics and treatment-related characteristics, such as the number of interlocking screws, segmentation length, main third fragment length, distance of the main third fragment, width ratio and exposed nail length in one cortex from immediate post-operative radiographs. Multivariate logistic regression was used for statistical analysis. Among 2295 femoral shaft fracture patients from three level-1 trauma centers, 51 met the inclusion criteria. The radiological union was achieved in 37 patients (73%) with a mean union time of 10.7 ± 4.8 months. The acceptable axial alignment was observed in 30 patients (59%). Multiple logistic regression analysis identified only exposed nail length as a significant risk factor for non-union (odds ratio: 1.599, p = 0.003) and the cut-off value was 19.1 mm (sensitivity, 0.786; specificity, 0.811). The study revealed high rates of non-union (27%) and malalignment (41%). Therefore, patients who underwent intramedullary nailing with an exposed nail length greater than 19.1 mm or about twice the nail diameter should be cautioned of the potential non-union.

Treatment of Length-Unstable Pediatric Femur Fractures in Children Aged 5 to 11 years: A Focused Review.

Pediatric femur fractures in children aged 5 to 11 years are typically classified as length-stable versus length-unstable. For length-stable fracture patterns, there is frequent consensus among pediatric orthopaedic specialists regarding the appropriateness of flexible intramedullary nails, submuscular plates (SMP), or lateral-entry rigid intramedullary nails (LE-RIMN). With length-unstable fracture patterns, however, the decision is more complex. Age, weight, fracture pattern, fracture location, surgical technique, surgeon experience, several implant-specific details, and additional factors are all important when choosing between flexible intramedullary nail, SMP, and LE-RIMN. These familiar methods of fixation may all be supported by conflicting and sometimes heterogeneous data. When planning to treat length-unstable fractures in young children, surgeons should understand evidence-based details associated with each implant and how each patient-specific scenario affects perioperative decisions.