Incidence and Risk Factors of Osteonecrosis of the Femoral Head after Cephalomedullary Nailing for Pertrochanteric Fractures: Observational Single-Center Study.

Background: The objective of this study was to investigate the incidence of osteonecrosis of the femoral head (ONFH) after cephalomedullary nailing in elderly patients with pertrochanteric fractures and to analyze the risk factors related to ONFH. Methods: A total of 689 consecutive patients with cephalomedullary nailing for pertrochanteric fractures at our hospital were recruited. Of these, 368 patients who met the inclusion criteria were finally enrolled. ONFH after cephalomedullary nailing was identified by reviewing patients' electronic charts and serial radiographs. The ONFH group was then compared with the non-ONFH group. Results: ONFH was identified in 9 of 368 patients (2.4%). The time to diagnosis of ONFH averaged 23.8 months (range, 5-54 months) after index surgery. The mean age, body mass index, and bone mineral density (T-score in femur neck) were 84.1 ± 7.1 years, 23.7 ± 3.6 kg/m2, and -3.1 ± 0.7 kg/m2, respectively. The times from injury to surgery, from admission to surgery, and operation time averaged 4.2 ± 2.7 days, 3.6 ± 2.6 days, and 87.2 ± 30.0 minutes, respectively. Among 9 patients, 3 underwent conversion arthroplasty. The ONFH group had advanced age (p = 0.029), more basicervical fracture components (p = 0.002), and inadequate reduction (p = 0.045) compared to the non-ONFH group. On multivariate analysis, advanced age (odds ratio [OR], 1.61;, p = 0.022), basicervical fracture components (OR, 24.58; p = 0.001), and inadequate reduction (OR, 4.11; p = 0.039) were identified as risk factors of ONFH. Conclusions: Although ONFH is relatively rare after cephalomedullary nailing for pertrochanteric fractures in elderly patients, its risk may increase with advanced age, basicervical fracture components, and inadequate reduction. Therefore, in patients with these risk factors, meticulous and longer follow-up is needed even after bone union.

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

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

Postoperative pneumonia after femoral fracture surgery: an in-depth retrospective analysis.

BACKGROUND: Femoral fractures significantly contribute to disability, predominantly in the elderly. Despite this, data on postoperative pneumonia following femoral fracture surgeries remains sparse. Our study sought to explore the incidence and impact of postoperative pneumonia on outcomes following such surgeries. METHODS: A retrospective study analyzed femoral fracture patients hospitalized from 2016 to 2022. We scrutinized postoperative outcomes, including pneumonia, hospital stay duration, intensive care unit (ICU) admissions, and in-hospital mortality. We established stringent diagnostic criteria for postoperative pneumonia, incorporating both clinical signs and radiological evidence, excluding patients with prior infections or those discharged within 24 h post-surgery. Statistical analyses involved Chi-square and t-tests, linear regression, and logestic regression using SPSS. RESULTS: Out of 636 patients, 10.8% were diagnosed with postoperative pneumonia. The average age was 79.55 ± 8.57 years, with a male prevalence of 47.8%. Common comorbidities were hypertension (78.3%), diabetes (60.9%), and cardiovascular diseases (40.6%). Surgical interventions were categorized as intramedullary nailing (40.6%), partial hip replacement (37.7%), and dynamic hip screw (21.7%). Postoperative pneumonia was associated with older age (AOR = 1.053, 95% CI 1.020 to 1.087, p = 0.002), ICU admission (AOR = 2.283, 95% CI 1.256 to 4.148, p = 0.007), and longer length of hospital stay (AOR = 1.079, 95% CI 1.030 to 1.130, p = 0.001). The presence of pneumonia was associated with a 2.621-day increase in hospitalization after adjusting for other variables (p < 0.001, 95% CI: 1.454 to 3.789). CONCLUSION: This study accentuates the clinical significance of postoperative pneumonia in femoral fracture patients, with a noted incidence of 10.8%. A notable association with older age, prolonged hospital stays, and ICU admissions was observed, underscoring the necessity of addressing this complication to improve patient outcomes and healthcare resource allocation.

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.

Extending the intermedullary nail will not reduce the potential risk of femoral head varus in PFNA patients biomechanically: a clinical review and corresponding numerical simulation.

Femoral head varus is an important complication in intertrochanteric fracture patients treated with proximal femoral nail anti-rotation (PFNA) fixation. Theoretically, extending the length of the intramedullary nail could optimize fixation stability by lengthening the force arm. However, whether extending the nail length can optimize patient prognosis is unclear. In this study, a review of imaging data from intertrochanteric fracture patients with PFNA fixation was performed, and the length of the intramedullary nail in the femoral trunk and the distance between the lesser trochanter and the distal locking screw were measured. The femoral neck varus status was judged at the 6-month follow-up. The correlation coefficients between nail length and femoral neck varus angle were computed, and linear regression analysis was used to determine whether a change in nail length was an independent risk factor for femoral neck varus. Moreover, the biomechanical effects of different nail lengths on PFNA fixation stability and local stress distribution have also been verified by numerical mechanical simulations. Clinical review revealed that changes in nail length were not significantly correlated with femoral head varus and were also not an independent risk factor for this complication. In addition, only slight biomechanical changes can be observed in the numerical simulation results. Therefore, commonly used intramedullary nails should be able to meet the needs of PFNA-fixed patients, and additional procedures for longer nail insertion may be unnecessary.

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.

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.

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.

The Effect of Intraoperative Patient Positioning on the Success of Intertrochanteric Fracture Surgery in Older Patients.

Background and Objectives: The incidence of hip fractures in people of advanced ages is increasing due to our aging society. Patient positioning for the intertrochanteric fractures of the femur can be performed in various ways. The aim of this study is to clinically and radiologically compare the use of the supine hemilithotomy position, the lateral decubitus position, and the traction table when performing proximal femoral nail (PFN) surgery for femoral intertrochanteric fractures in the geriatric age group. Materials and Methods: A total of 170 elderly patients with femoral intertrochanteric fractures were included in this cross-sectional study. The patients were divided into three groups (the supine hemilithotomy group, the lateral decubitus group, and the fracture table group). For the postoperative period, complications, length of stay in the intensive care unit, and length of stay in hospital were examined, while in postoperative radiographs, tip-apex distances (TADs), collodiaphyseal angles (CDAs), and Cleveland-Bosworth quadrants were examined to evaluate the placement of the lag screw in the femoral head. The quality of fracture reduction was evaluated according to the modified Baumgaertner criteria. Results: The mean age of the patients was 77.8 ± 8.8; 57.6% of patients were female. According to the modified Baumgaertner criteria, it was determined that patients with 'poor' reduction quality had an approximately ten times higher risk of cut-out than those with 'good' reduction quality (OR = 10.111, p = 0.002, 95% confidence interval; 2.313-44.207). The operative time for patients in the fracture table group was longer than that of the other groups Additionally, the CDA in the supine hemilithotomy position group was longer. Conclusions: Although PFN surgery using the traction table is longer in terms of surgical time compared to surgery performed in the lateral decubitus position and the supine hemilitotomy position, it is advantageous in terms of better TAD and CDA values and lower complication rates.

Background factors for intra-operative hypotension during hip fracture repair surgery in the elderly under spinal anesthesia managed by orthopedic surgeons: A retrospective case-control study.

BACKGROUND: Spinal anesthesia is used for femoral trochanteric fracture surgery, but frequently induces hypotension and the causative factors remain unclear. We examined background factors for the use of an intraoperative vasopressor in elderly patients receiving spinal anesthesia for femoral trochanteric fracture surgery. METHODS: We retrospectively analyzed 203 patients >75 years (mean age, 87.9 years) with femoral trochanteric fractures who underwent short nail fixation under orthopedically managed spinal anesthesia at our hospital between April 2020 and July 2023. Patients were divided into two groups: group A (intraoperative vasopressor) and group B (no vasopressor). The following data were compared: age, sex, height, weight, body mass index, antihypertensive medication, years of experience as a primary surgeon, bupivacaine dose, puncture level, anesthesia time, operation time, hemoglobin level and blood urea nitrogen/creatinine ratio on the day of surgery, brain natriuretic peptide level, left ventricular ejection fraction, and percentage of patients operated on the day of transport. RESULTS: There were 65 patients in group A and 138 in group B. The average dose of bupivacaine was 11.7 mg. In a univariate analysis, group A was slightly younger (87.0 vs. 88.3 years), had a higher blood urea nitrogen/creatinine ratio (27.1 vs. 24.5), more frequently received ß-blockers (14.1% vs. 5.8 %) and diuretic medications (21.9% vs. 11.6 %), and had a higher puncture level. A logistic regression analysis identified younger age (p = 0.02) and diuretic medication (p = 0.001) as independent risk factors in group A. Vasopressor use was more frequent at a higher puncture level in group A (57 % for L2/3, 33 % for L3/4, 15 % for L4/5, 0 % for L5/S). CONCLUSIONS: Spinal anesthesia-induced hypotension is attributed to volume deficit or extensive sympathetic blockade and may be prevented by avoiding high puncture levels and increasing preoperative fluid supplementation in patients on diuretics. There is currently no consensus on anesthetic dosages.

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.

Clinical efficacy and complications of blocking screw in the treatment of lower limb long bone fracture: An updated systematic review and meta-analysis.

BACKGROUND: Blocking screw technique has been widely applied in the treatment of long shaft fractures. However, the evidence with regard to whether intramedullary nail combined with blocking screw technique has better clinical efficacy over other is not clear. The aim of the study was to explore the clinical efficacy and complications of intramedullary nail combined with blocking screw technique in the treatment of femoral or tibial shaft fractures. METHODS: The PuMed, Embase, OVID, Cochrane library, Web of Science, Wanfang, CNKI and Weipu data were searched for studies of intramedullary nail combined with blocking screw in treatment of femoral or tibial shaft fracture published up to Aug 31 2023. Methodological quality of the trials was assessed, relevant data were extracted, and RevMan 5.3 and Stata 15.0 software were used to perform the meta-analysis of parameters related to the consequences. RESULT: Twenty articles were included, including 1267 patients. Meta-analysis results showed that compared with the non-blocking screw group, the blocking screw group had longer operation time (WMD = 13.24; 95% CI = 5.68-20.79, P = .0006) and more intraoperative fluoroscopy times (WMD = 57.62; 95% CI = 25.82-89.42, P = .0002). However, the postoperative therapeutic response rate was higher (OR = 5.60; 95% CI = 2.10-14.93, P = .0006), postoperative ankle joint function was better (OR = 3.48; 95% CI = 1.20-10.13, P = .02), and fracture healing rate was higher (OR = 3.56; 95% CI = 1.43-8.89, P = .006), fracture healing time was shorter (WMD = -3.59; 95% CI = -4.96 to -2.22, P < .00001), intraoperative blood loss was less (WMD = -54.80; 95% CI = -88.77 to -20.83, P = .002), hospitalization time was shorter (WMD = -1.66; 95% CI = -2.08 to -1.24, P < .00001), and complications were less (OR = 0.38; 95% CI = 0.16-0.89, P = .01). There was no statistical significance in the range of motion of knee joint between the 2 groups (WMD = 10.04; 95% CI = -1.51 to 21.59, P = .09). CONCLUSIONS: Current evidence shows that intramedullary nail combined with blocking screw technique in the treatment of lower limb long bone fracture has the advantages of good clinical efficacy, high fracture healing rate, short fracture healing time, good joint function, less complications and so on, which is worthy of clinical recommendation.

Risk of complications and implant survival of surgical treatment of proximal femoral metastasis: a meta-analysis.

PURPOSE: The patients with femoral metastasis in the inter- or subtrochanteric area could be treated with intramedullary nailing or prosthetic reconstruction, however, it is controversial which surgical treatment could offer less complications and implant failure. Our purpose was to define the risk of complications and implant survival in patients treated with intramedullary nailing or prosthetic reconstruction. METHODS: We analyzed studies reporting the risk of complications, reoperations and removal of the implant in patients treated with intramedullary nailing, hemiarthroplasty, arthroplasty or megaprosthesis. RESULTS: We analyzed 27 studies (1346 patients) reporting patients treated with intramedullary nail (51%), hemiarthroplasty (15%), arthroplasty (2%), megaprosthesis with (25%) or without (7%) acetabular component. No difference was found in the overall risk of complications between patients treated with intramedullary nailing 6%, hemiarthroplasty or total hip arthroplasty 7% and megaprosthesis 11% (p = 0.23). However, patients treated with megaprosthesis had increased risk of reoperation due to infection (70%), compared to the patients treated with intramedullary nail (13%), and patients treated with hemiarthroplasty or total hip arthroplasty (23%) (p = 0.02). Revision due to disease progression was required in 61% of the patients treated with intramedullary nail, but not in patients treated with hemiarthroplasty, total arthroplasty, and megaprosthesis (p = 0.03). CONCLUSION: Patients treated with megaprosthesis had higher risk of reoperation due to infection, while patients treated with intramedullary nailing had higher risk of revision due to disease progression. Regarding patients treated with megaprosthesis, the risk of reoperation due to dislocation was higher in those treated with acetabular component.

Infrapatellar branch of the saphenous nerve lesion following tibial nailing: it is possible to avoid it?

BACKGROUND: Iatrogenic injury to the infrapatellar branches of saphenous nerve is a common complication following tibial nailing. This lesion seems to be directly related to the surgical approach adopted for nail insertion. The aim of the present study was to systematically review the current literature in order to assess the eventual superiority of one surgical approach for tibial nailing over the others in limiting the neurological impairment related to infrapatellar branch injury. MATERIALS AND METHODS: The available literature was systematically screened searching papers dealing with iatrogenic injury to the infrapatellar branch of saphenous nerve after intramedullary tibial nailing. The terms "Saphenous" and "Infrapatellar branch" were used in combination with "intramedullary nailing" and "tibial fractures", supplying no limits regarding the publication year. Only publications in English were considered. Case reports, technical notes, instructional course, literature reviews, biomechanical and/ or in vitro studies were all excluded. Coleman methodological score was performed in all the retained articles. RESULTS: Four articles matched the inclusion criteria. There were one original article and three retrospective study. Hypoesthesia and a larger extension of the area of sensory-loss were more frequently observed after vertical incision approach in three out of four articles. A trend towards a lower rate of iatrogenic nerve damage using a transverse incision was found in the remaining one, without any statistical significance. CONCLUSIONS: In order to avoid infrapatellar nerve lesion, horizontal or oblique incisions or percutaneous approaches should be favored, although in some cases a longitudinal incision is required. Limited-extension incisions could minimize the risk and the incidence of this complication.

Management of Length Unstable Femur Fractures in Children by Flexible Intramedullary Nails: A Systematic Review.

PURPOSE OF THE STUDY: Surgical options for paediatric femoral fractures include fl exible intramedullary nailing (FIN), plating, and external fi xators. Length unstable fractures are usually spiral, long oblique, or comminuted and are often associated with > 2 cm of shortening. The purpose of this study was to see whether FIN is effective for managing unstable femur fractures in children. MATERIAL AND METHODS: An electronic literature search was performed up to 25 February 2022 in Cochrane Library, PubMed, and Embase databases using a combination of MeSH search terms and keywords related to the population (e.g., "child" AND "diaphyses" AND "femur"), and intervention (e.g., "nail" OR "ESIN"). The data extracted included the study details, Demographic data, surgical details, postoperative immobilization, complications, and outcome. RESULTS: Eight studies with a total sample size of 369 patients were reviewed. The mean operative time, blood loss, and length of stay in the hospital were 67.62±12.32 minutes, 33.82±16.82 ml, and 4.9±1.27 days, respectively. The results were excellent in 61.92% of the patients, satisfactory in 32.61%, and poor in 5.43%. 4.54% of patients had major complications requiring reoperation and 32.46% of patients had minor complications. the most common complication was nail prominence seen in 26.30% of patients. Locked Ender's nail was associated with the least reoperation, malunion, and LLD rate compared to other types of FIN. CONCLUSIONS: FIN along with a single walking spica cast is a good choice in all forms of paediatric femoral fracture patterns allowing proper alignment and rotation. Locked Ender's nail is safe and effective for managing unstable paediatric femur fracture. KEY WORDS: pediatric femur fracture, length unstable, fl exible intramedullary nailing, submuscular plating, Flynn criterion.

Rotational Malalignment After Intramedullary Nailing of Tibial Shaft Fractures Is Predictable.

OBJECTIVES: Intramedullary nailing is the treatment of choice for most tibial shaft fractures (TSF). However, an iatrogenic pitfall may be rotational malalignment. The aim of this retrospective analysis was to determine predictors of rotational malalignment following intramedullary nailing of TSF. DESIGN: Retrospective study. SETTING: Single level 1 trauma center. PATIENT SELECTION CRITERIA: Patients who had a unilateral intramedullary nailing for TSF with a low-dose bilateral postoperative CT to assess rotational malalignment. OUTCOME MEASURES AND COMPARISONS: Bivariable analysis followed by multivariable analysis was then undertaken to assess for any independent predictors, such as fracture type/sight, surgeon experience, and side of fracture, predictive of rotational malalignment. RESULTS: In total, 154 patients (71% male, median age 37 years) were included in this study. Thirty-nine percent of variability in postoperative rotational malalignment could be explained using a model including (increased) tibial torsion of the noninjured side (mean [38.9 degrees ± 9.02 degrees] considered normal tibial torsion), side of tibial fracture, and spiral-type tibial fracture (R2 = 0.39, P ≤ 0.001, F = 31.40). In this model, there was a negative linear association between degrees of torsion on the noninjured side and rotational malalignment (-0.45, P < 0.001)-as baseline torsion increased from mean by 1 degree, malrotation in the opposite direction of 0.54 degrees seen. Positive linear associations between right-sided TSF and rotational malalignment (8.59 P < 0.001) as well as spiral fractures and rotational malalignment (5.03, P < 0.01) were seen. CONCLUSIONS: This study demonstrates that baseline reduced (internal) tibial torsion of the noninjured limb, spiral fractures, and right-sided TSF are predictive of postoperative external rotational malalignment. Conversely, increased baseline (external) tibial torsion of the noninjured limb and left-sided TSF are predictive of postoperative internal rotational malalignment. Surgeons may use this regression model preoperatively to predict what sort of postoperative rotational difference their patient may be prone to. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Laterally Protruded Cephalomedullary Nail Lag Screws are a Source of Consistent Thigh Pain After Pertrochanteric Fracture.

OBJECTIVES: To assess the correlation between the amount of proximal screw lateralization and clinical symptoms in patients treated with a cephalomedullary nail (CMN) after a pertrochanteric fracture. DESIGN: Retrospective study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients operated for a pertrochanteric fracture (OTA/AO A1, A2, A3) between 2019 and 2022 and treated with a CMN were included. OUTCOME MEASURES AND COMPARISONS: Three measurements were evaluated: D1 distance between the most laterally prominent point of the lag screw and the line tangent to the greater trochanter, D2 distance between the lateral femoral cortex and the most laterally prominent point of the lag screw, and D3 distance between the point where the lag screw emerges at the lateral edge of the femur shaft and the skin's surface. Clinical scores and information regarding lateral thigh pain were obtained, and a correlation analysis was performed. RESULTS: Mean age of the study cohort (n = 134) was 77.9 ± 12.3 years. Patients with categorical protrusion (considered present in cases where the distance between the lateral tip of the lag screw and the lateral border of the greater trochanter was ≥0.2 mm) had significantly higher rates of lateral thigh pain ( P = 0.007) and discomfort while lying on the side ( P = 0.032) compared with those without protrusion. Correlation analyses showed a positive correlation between measurements D1 and D2 and lateral thigh pain (r = 0.324 and r = 0.334, respectively, P < 0.001) and a negative correlation between D3 and lateral thigh pain (r = -0.286, P = 0.001). Regression analysis showed that higher D1 and D2 distances and shorter D3 distances are risk factors for lateral thigh pain ( P = 0.001, 0.001, and 0.002, respectively). CONCLUSIONS: Increasing lateral protrusion of the lag screw leads to significantly greater clinical complaints and lateral hip pain in patients treated with a CMN. Patients with lower distance between the lateral femoral wall and the skin are at higher risk of lateral pain. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patient-Reported Outcome Measurement Information Systems Physical Function and Pain Interference Scores Are Correlated With Tibial Shaft Fracture Nonunion Following Intramedullary Nailing.

OBJECTIVES: To assess trends in Patient-Reported Outcome Measurement Information Systems (PROMIS) Physical Function (PF) and Pain Interference (PI) in surgically treated tibial shaft fracture patients progressing to union versus nonunion. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients with operatively treated tibial shaft fractures (AO/OTA 42-A, B, C) using an intramedullary nail. OUTCOME MEASURES AND COMPARISONS: PROMIS PF and PI were compared between patients progressing to union and patients requiring nonunion repair. RESULTS: A total of 234 patients (196 union, 38 nonunion) were included consisting 144 men and 90 women. The mean age of included patients was 40.8 years. A significant difference in mean PROMIS PF between union and nonunion patients was observed at 1-3 months ( P = 0.005), 3-6 months ( P < 0.001), 6-9 months ( P = 0.003), and 6-12 months ( P = 0.018). The odds of developing nonunion for every unit decrease in PROMIS PF was significant at 3-6 months (OR 1.07, P = 0.028) and 6-9 months (OR 1.17, P = 0.015). A significant difference in mean PROMIS PI between union and nonunion patients was observed at 1-3 months ( P = 0.001), 3-6 months ( P = 0.005), and 6-9 months ( P = 0.005). The odds of developing nonunion for every unit increase in PROMIS PI was significant at 1-3 months (OR 1.11, P = 0.005), 3-6 months (OR 1.10, P = 0.011), and 6-9 months (OR 1.23, P = 0.011). CONCLUSIONS: Poorly trending PROMIS PF and PI in the clinical setting is a factor that can be used to evaluate progression to nonunion following tibial shaft repair where imaging studies may lag behind. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early Complications of a Novel Retrograde Intramedullary Femoral Nail in the Treatment of Femur Fractures.

OBJECTIVES: To determine the early implant failure rate of a novel retrograde intramedullary femoral nail. DESIGN: Retrospective cohort study. SETTING: Academic level 1 trauma center. PATIENTS SELECTION CRITERIA: Patients aged 18 years and older with an acute OTA/AO 32-A, 32-B, 32-C, and 33-A fractures or periprosthetic distal femur fracture from April 2018 to April 2022 were included in the study. The 2 interventions compared were the Synthes Expert retrograde/antegrade femoral nail (or control implant) versus the next-generation retrograde femoral nail (RFN)-advanced retrograde femoral nail (RFNA or experimental implant) (Synthes, West Chester, PA). OUTCOME MEASURES AND COMPARISONS: Early implant-related complications between the experimental and control implants were assessed including locking screw back out, screw breakage, intramedullary nail failure, need for secondary surgery, and loss of fracture reduction. RESULTS: Three hundred fourteen patients were identified with a mean age of 31.0 years, and 62.4% of the patients being male. Open fractures occurred in 32.5% of patients with 3.8% of injuries being distal femur periprosthetic fractures. Fifty-six patients were in the experimental group and 258 patients in the control group. Mean follow-up was 46.8 weeks for the control cohort and 21.0 weeks for the experimental cohort. Distal interlocking screw back out occurred in 23.2% (13 of 56) of the experimental group patients and 1.9% (5 of 258) of the control group patients ( P < 0.0001). Initial diagnosis of interlocking screw back out occurred at an average of 3.2 weeks postoperatively (range, 2-12 weeks). Fifty-four percent of patients who sustained screw back out underwent a secondary operation to remove the symptomatic screws (12.5% of all patients treated with the experimental implant required an unplanned secondary operation due to screw back out). A logistic regression model was used to predict screw back out and found the experimental implant group was 4.3 times as likely to experience distal locking screw back out compared with the control group ( P = 0.01). CONCLUSIONS: The retrograde femoral nail-advanced implant was associated with a significantly higher rate of screw back out with a substantial number of unplanned secondary surgeries compared with the previous generation of this implant. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary nailing of femoral shaft fractures: an analysis of rotational malunions using 3D EOS.

PURPOSE: Rotational malalignment and leg length discrepancy after intramedullary nailing of femoral shaft are frequent. This study has three objectives: evaluate the rate of femoral rotational malalignment and leg length discrepancy using EOS imaging after antegrade intramedullary nailing of femoral shaft fracture, find a relevant clinical examination to detect malrotation and identified risk factors. METHODS: We performed a retrospective single-centre study between January 2014 and January 2022. Fifty-eight patients were clinically and radiographically assessed at a minimum of three months. RESULTS: The femoral rotation of the operated side was significantly greater by a mean of 15.4° in internal rotation compared to the healthy side. There was no statically significant difference for the femoral length (p = 0.08). CONCLUSION: When using EOS stereography following antegrade intramedullary nailing of post-traumatic diaphyseal femur fractures, a statistically significant difference of more than 15.4° in internal rotation was found for femoral rotation on the operated side compared to the healthy side.Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [B. Poirot] Last name [Seynaeve]. Also, kindly confirm the details in the metadata are correct.The last name of the first author was corrected : Given name = B. and last name = Poirot Seynaeve The details in matadata are correct LEVEL OF EVIDENCE: III.