The incidence of postoperative periprosthetic femoral fracture following total hip replacement: An analysis of UK National Joint Registry and Hospital Episodes statistics data.

BACKGROUND: Postoperative periprosthetic femoral fracture (POPFF) after total hip replacement (THR) requires complex surgery and is associated with a high morbidity, mortality, and cost. Although the United Kingdom based National Joint Registry (NJR) captures over 95% of THRs treated with revision, before June 2023 it did not capture POPFF treated with fixation. We aimed to estimate the incidence and epidemiology of POPFF treated with either surgery in England. METHODS AND FINDINGS: We performed a retrospective analysis of a mandatory, prospective database (NJR) linked to Hospital Episode Statistics (HES). All linkable primary THRs between 01/01/2004 and 31/12/2020 were included. Revision or fixation of POPFF were identified using a combination of procedural and diagnosis codes. We identified 809,832 THRs representing 5,542,332 prosthesis years at risk. A total of 5,100 POPFF were identified that had been surgically treated by revision, fixation, or both, and 2,831 of these fractures were treated with fixation alone, meaning 56% were not represented with revision data alone. The incidence of POPFF needing surgery was 0.92 (95% CI 0.90, 0.95) per 1,000 prostheses years. This incidence was higher in patients over the age of 70 at the time of primary THR (1.31 [95% CI 1.26, 1.35] per 1,000 prostheses years) and for patients who underwent THR for hip fracture (2.19 [95% CI 1.97, 2.42] per 1,000 prostheses years). This incidence appears to be increasing year on year. The cumulative probability of sustaining a POPFF within 10 years of THR was 1% and over 15% of patients died within 1 year of surgery for a POPFF. CONCLUSIONS: To date, the incidence of POPFF may have been underestimated with over 50% of cases missed if the case identification in this study is correct. After including these cases, we observed that POPFF is the largest reason for major reoperation following THR and patients sustaining these injuries have a high risk of death. The prevention and treatment of POPFF and requires further resource allocation and research.

The Effects of Phenyramidol and Diclofenac Treatment on Fracture Healing in Rats.

Background: Fracture healing or nonunion refers to a process in which many factors interact. In this study, we aimed to evaluate the radiological, histological, and biomechanical effects of phenyramidol and diclofenac, which are frequently used to treat post-fracture ture pain worldwide, on fracture healing and nonunion in a rat femur fracture model. Methods: In this study, 72 male Wistar-Albino rats aged 2-3 months and weighing 250 ± 30 g were divided into 4 main groups. The rats were divided into 12 subgroups according to the early, middle, and late periods. A fracture model was created in rat femurs, and surgical fixation was performed. Postoperative analgesic treatment protocols included phenyramidol, diclofenac, phenyramidol + diclofenac, and the control group. The rats were sacrificed on the fifteenth, thirtieth, and forty-fifth days and were evaluated radiologically, histopathologically, and biomechanically. Results: Scoring was conducted independently by 2 orthopedists not involved in the study. When the results were analyzed statistically, no statistically significant difference was observed between the fifteenth and thirtieth day radiology score values of the control, diclofenac, phenyramidol, and Phenyramidol + diclofenac groups (p > 0.05), but there was a statistically significant difference (p < 0.05) between the forty-fifth day radiology score values of the control, diclofenac, phenyramidol, and phenyramidol + diclofenac groups. Conclusions: Our study shows that the use of diclofenac or phenyramidol alone negatively affects postoperative fracture healing. However, this effect was less pronounced in the combined treatment group. Histologic examination revealed that neither treatment had a significant effect on healing. There were statistical differences in biomechanical and radiologic properties between the phenyramidol and diclofenac groups; in particular, the diclofenac group had lower biomechanical properties.

Results of Subtrochanteric Femoral Fractures Fixation by Proximal Femoral Locking Compression Plate.

The treatments of subtrochanteric femoral fractures are a challenge. It accounts about 10.0% to 34.0% of all hip fractures with a high complication rate. This area consists of mostly cortical bone with high stress generation thus heal slowly. The fracture is too proximal to adequately control with implants for femoral shaft and too distal to control with implants for intertrochanteric fractures. The intrinsic insecurity of this fracture and forces of the muscles with comminuted medial calcar is giving the fracture a tendency to varus crumple. Extramedullary implants are associated with higher rate of implant failure while intramedullary nails are not suitable for short proximal segment and wide medullary canal. Recently proximal femoral locking compression plate (PF-LCP) has been applied in treatment of proximal femur including subtrochanteric fractures. It has an excellent result in respect of union, fewer complications and early rehabilitation. The aim of this study was to assess the rate and time taken for union of fractures by PF-LCP and determine perioperative parameters. This prospective study was conducted from March 2019 to September 2020 at Mymensingh Medical College Hospital through non randomized purposive sampling. Total 25 patients aged above 18 years irrespective of sex with closed subtrochanteric fracture were included but pathological fractures, multiple injuries were excluded from the study. Union status evaluated by Radiographic Union Score for Tibial (RUST) fracture of Whelan; where antero-posterior and lateral radiographs (X-ray) based assessment of healing of the four cortices done. The entity cortical scores were added to give an entire score; 4 being the least amount demonstrating fracture are positively not healed and 12 being the highest score representing that the fracture is positively healed. The mean age of the patients was 42.04±14.97 years with range 22-70 years. Majority of patients were male (60.0%) and most of injury (64.0%) due to road traffic accident with most fractures was Seinsheimer type III (48.0%). Average operative time was 121.92 minutes, follow up period was 41.12 weeks (24-48 weeks) and time taken for union was 14.16 weeks (11-28 weeks). According to RUST scores; fracture union rate 88.0% with delayed union 12.0% and no nonunion. There were two patients with superficial wound infection and no implant failure. This study concludes that PF-LCP is a safe and reliable implant for the treatment of subtrochanteric femoral fractures.

[Rotationally stable screw anchor (RoSA) vs. Gamma3 Nail (G3N) in pertrochanteric femoral fractures : A functional outcome analysis]. / Rotationsstabiler Schraubanker (RoSA) vs. Gamma3-Nagel (G3N) bei pertrochantärer Femurfraktur : Eine funktionelle Outcome-Analyse.

BACKGROUND: The pertrochanteric femoral fracture (PFF) represents one of the most common fracture types throughout Germany. To enable early mobilization of patients, the primary surgical goal is load-stable osteosynthesis. Implant failure still represents the largest group of implant-related complications (>80%). OBJECTIVE: The aim of the study was to document and analyze the influence of the implant on the functional outcome and an evaluation of the rotationally stable screw anchor (RoSA) vs. Gamma3 nail. MATERIAL AND METHODS: In a retrospective study 43 patients with PFF (AO 31A1-A3) were included in the study. The influence of the implant on the functional outcome was assessed by 2 standardized questionnaires (SF-36, NMS (New Mobility Score)) and analyzed in a retrospective evaluation. RESULTS: In the study no significant differences in functional outcome scores ≥ 1 year after osteosynthesis of the PFF could be shown depending on the implant used. There is an overall tendency for a better outcome in the G3N group. DISCUSSION/CONCLUSION: In the literature the superiority of intramedullary nailing over extramedullary implants is continually discussed. Implant failure is still the most frequent complication. In intramedullary implants, such as the G3N, the primary cause is failure of the head-neck component. For conventional extramedullary implants the biomechanical properties on the femoral shaft also pose a challenge in the case of unstable PFF. The further development of the RoSA to an intramedullary implant could combine the advantages of intramedullary load carriers with the advantages of the blade-screw combination in the head-neck fragment and lead to a reduction in implant-associated complications.

[F-type forceps for assisted reduction in femoral shaft fractures surgery].

OBJECTIVE: To explore clinical efficacy of F-type forceps for assisted reduction in femoral shaft fracture reduction. METHODS: Forty-five patients with femoral shaft fracture treated with intramedullary nail and internal fixation from January 2019 to December 2021 were retrospectively analyzed and divided into two groups according to different reduction methods. In observation group, there were 21 patients, included 15 males and 6 females, aged from 27 to 92 years old with an average of (53.38±18.81) years old;9 patients on the left side, 12 patients on the right side;7 patients were type A, 8 patients were type B and 6 patients were type C according to AO fracture classification;the time from injury to operation ranged from 7 to 13 days with an average of (4.62±3.34) days;reduction was assisted by F-shaped forceps. In control group, there were 24 patients, including 17 males and 7 females, aged from 20 to 92 years old with an average of (51.96±20.43) years old;12 patients on the left side, 12 patients on the right side;11 patients were type A, 8 patients were type B and 5 patients were type C according to AO fracture classification;the time from injury to operation ranged from 2 to 13 days with an average of (6.29±3.04) days;traditional reset mode was adopted. Operative time, intraoperative blood loss, intraoperative fluoroscopy times, intraoperative open reduction ratio, clinical healing time of fracture, postoperative complications, hospital stay, hospital cost and Lysholm score of knee joint at 6 and 12 months after surgery were compared between two groups to evaluate clinical effect. RESULTS: All patients were followed up for 12 to 24 months with an average of (16.60±3.45) months. In observation group, operative time, intraoperative blood loss, intraoperative fluoroscopy times, open reduction cases, and clinical healing time of fractures were (58.19±7.93) min, (88.10±44.45) ml, (25.29±5.54) times, 0 case, (4.76±0.77) months, respectively;while in control group was (79.33±22.94) min, (222.92±144.45) ml, (47.46±26.25) times, 5 cases, (7.13±1.80) months, and the difference between two groups were statistically significant (P<0.05). There were no significant difference in postoperative complications, length of stay and hospitalization cost between two groups (P>0.05). At 6 months after surgery, Lysholm score of knee joint in observation group (88.62±4.48) was better than that in control group (79.21±8.91) (F=21.948, P=0.000). There were no significant difference in support use, pain and squat score between two groups (P>0.05). At 12 months after surgery, Lysholm scores of stair climbing and pain in observation group were (9.62±1.20) and (19.76±1.92), which were better than those in control group (7.83±2.04) and (21.88±2.88) (P<0.05). There were no significant difference in scores and total scores of other items between two groups (P>0.05). CONCLUSION: Compared with traditional reduction method, F-type forceps instrument could shorten operation time, reduce intraoperative blood loss, reduce intraoperative fluoroscopy times, accelerate clinical healing of fracture, and promote earlier functional recovery of knee joint.

Surgical outcomes of cable plate fixation in treatment of Vancouver type B1 and type C periprosthetic femoral fractures: a retrospective case series.

This study aimed to investigate the mid-to-long-term surgical outcomes of open reduction and internal fixation (ORIF) using a hybrid locking plate/cable technique for the treatment of Vancouver type B1 and type C periprosthetic femoral fractures (PPFs) in a consecutive group of patients from a single tertiary referral center. Twenty-five patients (25 PPFs; 17 female, 8 male) in whom a Vancouver type B1 or type C PPF was diagnosed and treated by a hybrid locking plate/cable technique from 2005 to 2016 were included in the study. Patients' functional status was categorized into 4 groups based on the Harris Hip Score (HHS) at the final follow-up: 70=poor result; 70-80=fair; 80-90=good, and 90-100=excellent. Intraand postoperative complications were also recorded. PPF union was defined clinically as the patient's ability to bear full weight with or without assistance and radiographically as the presence of a callus bridging the fracture. Subgroup analyses were conducted according to the Vancouver classification and type of fixation regarding the HHS and time to union. The mean age was 57 ± 16.6 (range, 17-82) years at the time of the primary hip replacement and 64 ± 18.7 (range, 24-88) years at the time of PPF. The mean follow-up was 5.6 ± 3.3 (range, 2-14) years from primary procedure to PPF and 6.5 ± 4.1 (range, 3-15) years following PPF. There were 7 type B1 and 18 type C PPFs. At the final follow-up, the mean HHS was 71 ± 7.74 (range, 57-89). According to HHS, functional results were poor in 8 patients, fair in 14 patients, and good in 3 patients. No major intra- or postoperative complications were noted. Fracture union was achieved in all patients without complications at an average of 13 ± 4.9 (range, 6-24) weeks. In subgroup analysis, while no significant differences were observed in the HHS (P=.87 for the Vancouver type, P=.96 for the type of fixation), time to union differed among groups. Time to union was significantly shorter in type B1 than in type C PPFs (P=.006). Time to union was considerably shorter in the uncemented group compared to the cemented one (P=.017). Adding cables to the locking plate can provide adequate stability to preserve fracture alignment and achieve bony union in Vancouver type B1 and C PPFs. Although union can be achieved by ORIF in such patients, a longer union time may be required for PPFs in the setting of a cemented femoral stem or Vancouver type C. Level IV, Therapeutic study.

[Standard radiographic images in cephalomedullary nailing fixation for intertrochanteric femoral fractures].

Objective: To review and summarize the projections of radiographic images during cephalomedullary nailing fixation for intertrochanteric femoral fractures, and to propose a set of three projections as standard requirement in immediate postoperative fluoroscopy. Methods: Papers on intertrochanteric femoral fractures treated with cephalomedullary nailing fixation that published in a three-year period of 2021-2023 in four leading English orthopedic trauma journals were searched in PubMed. The presented radiographic pictures were identified and scrutinized as whether they were in standard anteroposterior and/or lateral projections of the implanted nails. The nonstandard presence percentage was calculated. Combined with clinical experience, the standard anteroposterior and lateral perspective images of femoral neck, the current situation of radiographic imaging in the operation of cephalomedullary nails, the literature analysis of nonstandard images, the impact of limb rotation on image interpretation, and the characteristics of anteromedial 30° oblique perspective were summarized and analyzed. Results: The presence of nonstandard radiographic pictures is 32.1% in anteroposterior view and 69.2% in lateral view in leading orthopedic trauma journals. In cephalomedullary nailing fixation operation of intertrochanteric femoral fractures, it is reasonable to use the radiographic images of the implanted nails to represent the fractured head-neck, as the head-neck implant (lag screw or helical blade) is aimed to put into centrally in femoral head in lateral projection. Limb rotation or nonstandard projections produced distortion of images, which interfers the surgeons' judgement of fracture reduction quality and the measurement of implant position parameters in femoral head (such as neck-shaft angle and tip-apex distance), and finally lead to a meaningless comparison with the accurate normal value. The 30° anteromedial oblique view from the true lateral (set as 0°) is a tangential projection of the cortices at the anteromedial inferior corner, which gives a clear profile for the determination of cortical apposition status and mechanical support. It is essential to get firstly the true standard lateral fluoroscopy of the nail (shown as a line), then rotate the C-arm to 90° and 30° to get anteroposterior and anteromedial oblique views, and use these three immediate postoperative radiographies as the baseline for evaluation of operative quality and follow-up comparisons. Conclusion: As for real-time monitoring of surgical steps, intraoperative fluoroscopy follows the "Enough is Good" principle, but as for immediate postoperative data storage and basis for operative quality evaluation and baseline for follow-up comparison, it is recommended to obtain a set of three standard radiographic pictures in anteroposterior, true lateral, and 30° anteromedial oblique fluoroscopic projections.

SIMBA-A Single-Puncture Approach to Lower Limb Block.

Peripheral nerve blocks provide a safe and reliable alternative in the anesthetic management of femur fractures in elderly subpopulations associated with significant comorbidities. Single-Insertion Multiple Nerve Block Anesthesia (SIMBA) is a technique where a single needle insertion is used to block all four nerves that supply the femur shaft: the femoral nerve, obturator nerve, lateral femoral cutaneous nerve, and sciatic nerve. The authors performed this technique in 11 cardiac compromised geriatric patients with midshaft/distal femur fractures, and the surgery was conducted successfully without any significant hemodynamic change and good postoperative analgesia.

Increased risk of intraoperative and early postoperative periprosthetic femoral fracture with compaction compared with broaching in cementless THA: a single-center study of 6,788 hips.

BACKGROUND AND PURPOSE:  Periprosthetic femoral fracture (PFF) is a significant complication of total hip arthroplasty (THA). Although biomechanical studies have indicated that the technique by which the femoral canal is prepared plays a role, few clinical studies have reported on how this might affect the fracture risk. This study compares the fracture risk between compaction and broaching with toothed instruments in cementless THA. METHODS: Prospectively collected data from the quality register of a high-volume hospital was used. All primary arthroplasties using the Corail stem (DePuy Synthes) were included. All femoral fractures occurring within the first 90 days after the operation were included in the analysis. We determined the relative risk of sustaining PFF with compaction compared with broaching and adjusted for confounders (sex, age group, BMI, and use of a collared stem) using multivariable Poisson regression. RESULTS:  6,788 primary THAs performed between November 2009 and May 2023 were available for analysis. 66% were women and the mean age was 65.0 years. 129 (1.9%) fractures occurred during the first 90 days after the operation, 92 (2.3%) in the compaction group and 37 (1.3%) in the broaching group. The unadjusted relative risk of fracture in the compaction group compared with the broaching group was 1.82 (95% confidence interval [CI] 1.25-2.66), whereas the adjusted relative risk was 1.70 (CI 1.10-2.70). CONCLUSION: Compaction was associated with more periprosthetic fractures than broaching (2.3% versus 1.3%) within 90 days after surgery.

A Scoring System for Predicting Nonunion After Intramedullary Nailing of Femoral Shaft Fractures.

INTRODUCTION: Femoral shaft nonunion negatively affects patient quality of life. Although multiple risk factors have been identified for femoral shaft nonunion after intramedullary nail (IMN) fixation, there is no quantitative model for predicting nonunion. STUDY DESCRIPTION: The study is a retrospective cohort study of patients with femoral shaft fractures treated at two level one trauma centers who were followed to fracture union or nonunion. Patient, injury, and surgical characteristics were analyzed to create a quantitative model for nonunion risk after intramedullary nailing. METHODS: Eight hundred one patients aged 18 years and older with femoral shaft fractures treated with reamed, locked IMNs were identified. Risk factors including demographics, comorbidities, surgical variables, and injury-related characteristics were evaluated. Multivariate analysis was conducted, and several variables were included in a scoring system to predict nonunion risk. RESULTS: The overall nonunion rate was 7.62% (61/801). Multivariate analysis showed significant association among pulmonary injury (odds ratio [OR] = 2.19, P = 0.022), open fracture (OR=2.36, P = 0.02), current smoking (OR=3.05, P < 0.001), postoperative infection (OR=12.1, P = 0.007), AO/OTA fracture pattern type A or B (OR=0.43, P = 0.014), and percent cortical contact obtained intraoperatively ≥25% (OR=0.41, P = 0.021) and nonunion. The scoring system created to quantitatively stratify nonunion risk showed that a score of 3 or more yielded an OR of 6.38 for nonunion (c-statistic = 0.693, P < 0.0001). CONCLUSIONS: Femoral shaft nonunion risk is quantifiable based on several independent injury, patient, and surgical factors. This scoring system is an additional tool for clinical decision making when caring for patients with femoral shaft fractures treated with IMNs.

Distal femoral fractures: periprosthetic fractures have four times more complications than non-periprosthetic fractures and cerclage should be avoided: retrospective analysis of 206 patients.

BACKGROUND: Distal femoral fractures account for less than 1% of all fractures. The therapy of choice is usually surgical stabilization. Despite advances in implant development over the past few years, complication rate remains comparatively high. The aim of this study is to analyze our results with plate fixation of distal femoral fractures with a focus on complication and fracture healing rates. METHODS: In this retrospective cohort study, patients (> 18 years) with distal femoral fractures treated at an urban level I trauma center between 2015 and 2022 were analyzed. RESULTS: In total, 206 patients (167 female, 39 male) with an average age of 75 (SD 16) years were diagnosed with a fracture of the distal femur. One hundred fourteen of these patients were treated surgically by means of plate osteosynthesis. In 13 cases (11.41%), a revision procedure had to be performed. The indication for surgical revision was mechanical failure in eight cases (7.02%) and septic complication in five cases (4.39%). Periprosthetic fractures were more likely to cause complications overall (19.6% versus 4.76%) and further included all documented septic complications. The analysis of modifiable surgical factors in the context of plate osteosynthesis showed higher complication rates for cerclage in the fracture area compared with plate-only stabilizations (44.44% versus 22.22%). CONCLUSIONS: The data show an increased amount of revisions and a significantly higher number of septic complications in the treatment of periprosthetic fractures of the distal femur compared with non-periprosthetic fractures. The detected combination of plates together with cerclage was associated with higher complication rates. Level of evidence Level III retrospective comparative study.

Multilayer Gelatin-Supported BMP-9 Coating Promotes Osteointegration and Neo-Bone Formation at the n-CDHA/PAA Composite Biomaterial-Bone Interface.

BACKGROUND: The development of biomaterials capable of accelerating bone wound repair is a critical focus in bone tissue engineering. This study aims to evaluate the osteointegration and bone regeneration potential of a novel multilayer gelatin-supported Bone Morphogenetic Protein 9 (BMP-9) coated nano-calcium-deficient hydroxyapatite/poly-amino acid (n-CDHA/PAA) composite biomaterials, focusing on the material-bone interface, and putting forward a new direction for the research on the interface between the coating material and bone. METHODS: The BMP-9 recombinant adenovirus (Adenovirus (Ad)-BMP-9/Bone Marrow Mesenchymal Stem Cells (BMSc)) was produced by transfecting BMSc and supported using gelatin (Ad-BMP-9/BMSc/Gelatin (GT). Multilayer Ad-BMP-9/BMSc/GT coated nano-calcium deficient hydroxyapatite/polyamino acid (n-CDHA/PAA) composite biomaterials were then prepared and co-cultured with MG63 cells for 10 days, with biocompatibility assessed through microscopy, Cell Counting Kit-8 (CCK-8), and alkaline phosphatase (ALP) assays. Subsequently, multilayer Ad-BMP-9/BMSc/GT coated n-CDHA/PAA composite biomaterial screws were fabricated, and the adhesion of the coating to the substrate was observed using scanning electron microscopy (SEM). In vivo studies were conducted using a New Zealand White rabbit intercondylar femoral fracture model. The experimental group was fixed with screws featuring multilayer Ad-BMP-9/BMSc/GT coatings, while the control groups used medical metal screws and n-CDHA/PAA composite biomaterial screws. Fracture healing was monitored at 1, 4, 12, and 24 weeks, respectively, using X-ray observation, Micro-CT imaging, and SEM. Integration at the material-bone interface and the condition of neo-tissue were assessed through these imaging techniques. RESULTS: The Ad-BMP-9/GT coating significantly enhanced MG63 cell adhesion, proliferation, and differentiation, while increasing BMP-9 expression in vitro. In vivo studies using a rabbit femoral fracture model confirmed the biocompatibility and osteointegration potential of the multilayer Ad-BMP-9/BMSc/GT coated n-CDHA/PAA composite biomaterial screws. Compared to control groups (medical metal screws and n-CDHA/PAA composite biomaterial screws), this material demonstrated faster fracture healing, stronger osteointegration, and facilitated new bone tissue formation with increased calcium deposition at the material-bone interface. CONCLUSION: The multilayer GT-supported BMP-9 coated n-CDHA/PAA composite biomaterials have demonstrated favorable osteogenic cell interface performance, both in vitro and in vivo. This study provides a foundation for developing innovative bone repair materials, holding promise for significant advancements in clinical applications.

Prospective study on functional outcome of distal femur fracture treated by open reduction and internal fixation using distal femur locking plate in Tibebe Ghion Specialized Hospital, Bahirdar, North West Ethiopia.

BACKGROUND: Distal femur fractures account for 6% of femur fractures. The treatment of distal femur fractures is challenging. Historically, nonoperative management has been the mainstay of management, which has evolved to operative management. There is no single implant used for all types of distal femur fractures. The implant evolves with time. The introduction of a distal femur locking plate (DF LCP) has had a great impact on the treatment. In developing countries like Ethiopia, there is scarcity of studies on functional outcome of operative treatment. So, this study aimed to assess the functional outcome of distal femur fractures treatment using distal femur locking plate. METHODS: This prospective cohort study was carried out among adult patients with distal femur fractures treated using distal femur locking plate at Tibebe Ghion Specialized Hospital from august 2022 to July 2023. A total of 60 patients with AO Type A and Type C fracture were included. All patients were followed for 6 months. Functional outcomes were assessed using Neer's scoring system. Data was entered and analyzed using SPSS 27. Frequency, mean and cross tabulation were used to summarize descriptive statistics. Multinomial logistic regression was used to test the associations. RESULTS: In our study out of 60 patients ,48.3% (29) had excellent functional outcomes, 30% (18) had good functional outcomes, 10% (6) had fair functional outcomes and 11.7% (7) had unsatisfactory functional outcomes according to Neer's scoring system. Patients with closed distal femur fractures had 5 times higher probability of excellent functional outcome than those patients with open distal femur fractures (AOR (2.49(5.8 ,1.07)). Patients who had regular follow up had 7 times higher probability of excellent functional outcome than those who had no regular follow up (AOR 7.16(1.11,46.22)). The average union period was 4.63 months, with only 2 patients experiencing delayed union. CONCLUSION: Closed fracture and regular follow up were determining factors for better functional outcomes. Closed fractures preserve the biological environment, which facilitates early fracture healing. The regular follow up helped patients to assess their rehabilitation status and pick any complication early.

Anesthesia's Influence on Postoperative In-Hospital Morbidity-Mortality in Proximal Femoral Fractures in the Elderly.

Background and Objectives: The incidence of proximal femoral fractures (PFFs) is rising, causing significant morbidity and mortality. Regional anesthesia (RA)'s benefits include the avoidance of intubation and mechanical ventilation, decreased blood loss, and improved analgesia. General anesthesia (GA) offers improved hemodynamic stability. This study examines the in-hospital post-surgical morbidity and mortality seen in PFFs in a cohort of the elderly undergoing GA or RA. Materials and Methods: This is a retrospective cohort study of 319 PFF patients older than 65 years over a single year. Results: In total, 73.7% of patients underwent GA. The patient characteristics were identical between groups, except for smoking. Hypertension was the most frequent comorbidity, followed by hyperlipidemia, NIDDM, and IHD. The overall patient complication rate was 11.4%. Pneumonia was the most common complication (5.1% in GA, 8.4% in RA). A total of 0.9% of patients required ICU admission. Overall, the in-hospital mortality rate was 2.3%, with no statistically significant difference between GA and RA. The GA and RA cohorts were similar in terms of their patient demographics, medical history, and preoperative parameters. In total, 73% of surgeries were under GA. No statistically significant differences were found in total anesthesia time or complication rates. Conclusions: We did not find a difference between general and spinal anesthesia regarding complication rates, anesthesia time, or morbidity. General anesthesia remains best suited for patients receiving anticoagulation treatment and undergoing semi-urgent surgery, but, other than that, the mode of anesthesia administered remains up to the anesthesiologist's preference.

Titanium Cable Cerclage Increases the Load to Failure in Plate Osteosynthesis for Distal Femoral Fractures.

Background and Objectives: The reduction of two-part oblique or spiral fractures of the distal femur using steel wire cerclage prior to plate osteosynthesis is a proven procedure. In addition to being useful in fracture reduction, wire cerclage was also shown to increase the stability of osteosynthesis. Nevertheless, metal corrosion and the allergenic potency of steel remain problematic disadvantages of this method. A biomechanical study was carried out to evaluate titanium cable cerclage as an alternative supplement for plate osteosynthesis of a distal femoral two-part fracture. Materials and Methods: An unstable AO/OTA 32-A2.3 fracture was created in eleven pairs of nonosteoporotic human cadaver femora. All the samples were treated with polyaxial angular stable plate osteosynthesis. One femur from each pair was randomly selected for an additional fracture fixation with multifilament titanium cable cerclage. Stepwise cyclic axial loading was applied in a load-to-failure mode using a servohydraulic testing machine. Results: All specimens (mean age: 80 years; range: 57-91 years) withstood a cycling force of at least 1800 N. With a mean load of 2982 N (95% CI: 2629-3335 N), the pressure forces resulting in osteosynthesis failure were significantly higher in specimens with an additional titanium cerclage (Group 1) than in samples that were solely treated with plate osteosynthesis (Group 2) at 2545 N (95% CI: 2257-2834 N) (p = 0.024). In both groups, cutting out the distal screws at the condyle region, resulting in shearing of the distal fragment proximal to the fracture line, was the most frequent cause of construct failure. Among the specimens assigned to Group 1, 36% exhibited a specific fracture pattern, namely, a fracture of the dorsal buttress above the cerclage. Analysis of axial stiffness (p = 0.286) and irreversible deformity of the specimens revealed no differences between the groups (p = 0.374). Conclusion: Titanium cable cerclage application, as a supplement to an angular stable plate, resulted in an increased load to failure. In terms of stability, the use of this adjunct for fracture fixation of supracondylar two-part oblique femoral fractures might, therefore, be an option, especially in patients who are sensitive to nickel.

Medial plating of distal femur: which pre-contoured angular stable plate fits best?

PURPOSE: Distal femur fractures comprise approximately 4% of all femoral fractures, with lateral plating being a common fixation technique. In recent years, dual plating with an additional medial plate has shown added benefit for Arbeitsgemeinschaft für Osteosynthesefragen C-type fractures, comminuted, osteoporotic distal femur fractures and non-union or malunion complications postsingle lateral plating. However, to our knowledge, there is no commercially available distal femur medial plate for fracture fixation. The aim of our study was to determine which of our current commercially available pre-contoured plates fit the medial distal femur best in an Asian population. METHODS: We evaluated 13 different pre-contoured angular plates on standardized sawbone models. The plates were first applied onto the medial distal femur and subsequent anterior-posterior and lateral radiographs were taken postapplication. The appropriateness of the fit of each plate was objectively compared using a scoring system derived from pre-determined plate- and screw-related factors. RESULTS: The proximal humerus internal locking system plate had the best anatomical fit with the highest 'best fit score,' followed by the variable angle proximal tibia plate. CONCLUSION: While non-anatomical plates may be successfully utilized, in view of the anatomical variations of the femur, ultimately an anatomical plate for the medial distal medial femur should be developed for ease of fixation.

EFFECT OF A TRAINING PROGRAM ON REDUCING HEALTH COMPLICATIONS AFTER OPERATIONS OF PROXIMAL FEMORAL NAILING TECHNIQUE.

The proximal femoral fracture patients in particular fractures in the trochanteric region of the femur could have treatment under the title proximal femoral nailing (PFN)-this operation is a less invasive type. The proximal femoral nail, an osteosynthetic implant, has been investigated to produce positive heeling to ensure a better fixation, several advantages of PFN include such as bleeding time during operation which leads to the need to perform reaming on the femoral canal during surgery. MATERIAL AND METHODS: The study was carried out at three teaching Hospitals in Mosul City from the period of January 2022 to December 2022, fourteen nurses from orthopaedic wards were subjected to this study, all the nurses were evaluated by the checklist, and they attended the training program which was taken from the Iraqi Ministry of Health guide for organizing nursing operations and practices inside the hospitals and medical departments. RESULTS AND DISCUSSION: More than (50%) of the study sample had a poor score in the initial evaluation for post-operative steps and after submitting the training program, the performance and practices of the nursing staff have improved significantly where the poor score decreased to approximately (25%) at P value (0.0001). CONCLUSION: The study concluded that there is a significant and clear weakness in the performance and practices of the nursing staff towards patients with upper femoral fractures in the fracture wards and that the training program that was given to them improved their performance and practices significantly and effectively.

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.

Does gait influence biomechanics in a distal femoral osteotomy? An early post operative fracture after DFO above a Tomofix® plate in a multiple sclerosis and low-density bone affected patient: choose a longer plate-a case report.

BACKGROUND: Distal femur osteotomies are a well known and valuable treatment option to manage valgus malalignment with unicompartmental arthritis. Early postoperative complications are well known, and risk factors, such as pulmonary diseases, smoke, high dependent functional status, and body mass index, have been studied, but no study is available about osteotomies when gait is abnormal because of neurodegenerative conditions or when mineral density is below the normal rate. CASE PRESENTATION: We report the case of a 44 year-old female Mediterranean patient who underwent a biplanar distal femur opening wedge osteotomy surgery following a lateral meniscus total removal, which led to the subsequent development of lateral compartment osteoarthritis and pain, despite general comorbidities, such as multiple sclerosis. Additionally, 2 months later a supracondylar femur fracture above the previously applied Tomofix® plate was reported. Fracture was treated by applying a LCP condylar 16 hole (336 mm) plate, a structural fibular graft, and strut fibular graft on the opposite side. CONCLUSION: The overall aim of this case report is to provide a lesson to surgeons who want to perform a realignment surgery of the lower limb in patients with abnormal gait. Not only mechanical axes are to be considered, but also bone density, patient's gait, and load force distribution along the bone stock. Emerging literature on three-dimensional cutting guides fails to account for these factors, thus promoting a standardized approach to surgery across all patients. The present case highlights a patient with low bone density and abnormal force distribution resulting from a pathologic neurodegenerative gait. In such cases, treatment decisions must carefully consider the biomechanical vulnerabilities of the native bone and the distribution of vector forces. These conditions must lead the choice toward a longer plate if an osteotomy is indicated, because surgery is more likely to fail.